Provider Demographics
NPI:1194107490
Name:FULLER, KRISTEN MCDANIEL (CRNA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MCDANIEL
Last Name:FULLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 OLD ROCKY RIDGE RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35216-7235
Mailing Address - Country:US
Mailing Address - Phone:205-989-1080
Mailing Address - Fax:205-989-1087
Practice Address - Street 1:3316 HIGHWAY 280
Practice Address - Street 2:
Practice Address - City:ALEXANDER CITY
Practice Address - State:AL
Practice Address - Zip Code:35010-3369
Practice Address - Country:US
Practice Address - Phone:256-329-7146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-126963367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered