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General NPI Number Information
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NPI Number | 1659304384
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Entity Type | Individual
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Provider Name | MS. KONDRA MIA FULMER
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Gender | Female
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Dates
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Enumeration Date | 07/08/2006
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Last Update Date | 06/20/2024
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Provider Practice Location Address
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Address Line | 4850 MARK CENTER DR
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City | ALEXANDRIA
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State | VA
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Zip | 22311-1882
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Country | US
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Telephone | 703-746-3400
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Fax |
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Provider Business Mailing Address
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Address Line | 975 N SELOMONS ISLAND PO BOX 980
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City | PRINCE FREDERICK
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State | MD
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Zip | 20678
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Country | US
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Telephone | 410-535-5400
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Fax | 410-414-9413
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LC2175
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701006170
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License Number State | VA
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