Provider Demographics
NPI:1881904274
Name:FULLER, KATRINA LEANN (IBCLC, LCP)
Entity type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:LEANN
Last Name:FULLER
Suffix:
Gender:F
Credentials:IBCLC, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 E TAOS ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-1408
Mailing Address - Country:US
Mailing Address - Phone:575-392-4874
Mailing Address - Fax:
Practice Address - Street 1:212 E TAOS ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-1408
Practice Address - Country:US
Practice Address - Phone:575-392-4874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM174H00000X, 374J00000X
NM57759174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No174H00000XOther Service ProvidersHealth Educator
No374J00000XNursing Service Related ProvidersDoula