MEDICARE: FULFILLED MIND & WELLNESS PLLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1730045766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULFILLED MIND & WELLNESS PLLC

Provider Business Mailing Address
First Line	:	4117 S MERIDIAN
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98373-3697
Country	:	US
Telephone Number	:	253-648-0115
Fax Number	:	253-237-9314

Provider Business Practice Location Address
First Line	:	4117 S MERIDIAN
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98373-3697
Country	:	US
Telephone Number	:	253-648-0115
Fax Number	:	253-237-9314

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. STARLA HALVERSON
Credential	:	ARNP, PMHNP-BC
Telephone Number	:	509-833-4788

Provider Enumeration Date	:	01/03/2026
Last Update Date	:	01/03/2026

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