Healthcare Provider Details

I. General information

NPI: 1285549410
Provider Name (Legal Business Name): KRYSTAL FULLMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N MAIN ST
SPANISH FORK UT
84660-1726
US

IV. Provider business mailing address

9934 N 4680 W
CEDAR HILLS UT
84062-8706
US

V. Phone/Fax

Practice location:
  • Phone: 385-223-9215
  • Fax:
Mailing address:
  • Phone: 801-678-3995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: