Provider Demographics
NPI:1316256704
Name:FULLER, COLLEEN MARIE (ND)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:FULLER
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 SE KING RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2891
Mailing Address - Country:US
Mailing Address - Phone:503-546-6377
Mailing Address - Fax:503-546-9397
Practice Address - Street 1:6200 SE KING RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2891
Practice Address - Country:US
Practice Address - Phone:503-546-6377
Practice Address - Fax:503-546-9397
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1761175F00000X
WANT60737133175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2079454Medicaid