Healthcare Provider Details

I. General information

NPI: 1639019003
Provider Name (Legal Business Name): KOREN FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2026
Last Update Date: 03/28/2026
Certification Date: 03/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W 1ST AVE
COAL VALLEY IL
61240-9308
US

IV. Provider business mailing address

401 WALNUT ST
PORT BYRON IL
61275-9559
US

V. Phone/Fax

Practice location:
  • Phone: 309-799-7422
  • Fax:
Mailing address:
  • Phone: 309-644-9252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227023901
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: