Healthcare Provider Details

I. General information

NPI: 1891609988
Provider Name (Legal Business Name): MOLLY FULLENKAMP LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 IDLEWOOD CIR
EL SOBRANTE CA
94803-1115
US

IV. Provider business mailing address

835 IDLEWOOD CIR
EL SOBRANTE CA
94803-1115
US

V. Phone/Fax

Practice location:
  • Phone: 513-403-7508
  • Fax:
Mailing address:
  • Phone: 513-403-7508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number20728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: