Healthcare Provider Details

I. General information

NPI: 1659304384
Provider Name (Legal Business Name): MS. KONDRA MIA FULMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 MARK CENTER DR
ALEXANDRIA VA
22311-1882
US

IV. Provider business mailing address

975 N SELOMONS ISLAND PO BOX 980
PRINCE FREDERICK MD
20678
US

V. Phone/Fax

Practice location:
  • Phone: 703-746-3400
  • Fax:
Mailing address:
  • Phone: 410-535-5400
  • Fax: 410-414-9413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC2175
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701006170
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: