Healthcare Provider Details

I. General information

NPI: 1215840079
Provider Name (Legal Business Name): KRISSIE FULLMER SSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6364 S HIGHLAND DR STE 201
MURRAY UT
84121-2117
US

IV. Provider business mailing address

6210 S LINDSAY LN
HOLLADAY UT
84121-1205
US

V. Phone/Fax

Practice location:
  • Phone: 801-209-1357
  • Fax:
Mailing address:
  • Phone: 801-209-1357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number14201000-3503
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: