Healthcare Provider Details

I. General information

NPI: 1912165713
Provider Name (Legal Business Name): KISTI POPE FULLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KISTI DAWN POPE MD

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 S STAPLEY DR STE 131
MESA AZ
85204-6683
US

IV. Provider business mailing address

4343 N SCOTTSDALE RD STE 150
SCOTTSDALE AZ
85251-3351
US

V. Phone/Fax

Practice location:
  • Phone: 480-866-8787
  • Fax: 480-863-9770
Mailing address:
  • Phone: 480-866-8787
  • Fax: 480-863-9770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number24641
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number48767
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1912165713
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer
# 2
Identifier24641
Identifier TypeOTHER
Identifier StateNV
Identifier IssuerSTATE LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: