MEDICARE: MRS. KATHRYN AIMEE FULLER RN, CFNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	11440	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11440	OTHER	CA	CAL. LICENSE NUMBER

General Provider Information

NPI Number	:	1649371022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHRYN AIMEE FULLER RN, CFNP

Provider Business Mailing Address
First Line	:	1370 ROSECRANS ST
Second Line	:	STE A
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-2638
Country	:	US
Telephone Number	:	619-223-2668
Fax Number	:	619-223-2698

Provider Business Practice Location Address
First Line	:	1370 ROSECRANS ST
Second Line	:	STE A
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-2638
Country	:	US
Telephone Number	:	619-223-2668
Fax Number	:	619-223-2698

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	09/17/2008

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