1649371022 NPI number — MRS. KATHRYN AIMEE FULLER RN, CFNP

Table of content: (NPI 1477714012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649371022 NPI number — MRS. KATHRYN AIMEE FULLER RN, CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER
Provider First Name:
KATHRYN
Provider Middle Name:
AIMEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN, CFNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ERB
Provider Other First Name:
KATHRYN
Provider Other Middle Name:
AIMEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, CFNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649371022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1370 ROSECRANS ST
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92106-2638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-223-2668
Provider Business Mailing Address Fax Number:
619-223-2698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1370 ROSECRANS ST
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92106-2638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-223-2668
Provider Business Practice Location Address Fax Number:
619-223-2698
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  11440 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11440 . This is a "CAL. LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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