Provider Demographics
NPI:1427800697
Name:FULLER-ST.JOHN, ADRIANNE (PSYD)
Entity type:Individual
Prefix:
First Name:ADRIANNE
Middle Name:
Last Name:FULLER-ST.JOHN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-5800
Mailing Address - Country:US
Mailing Address - Phone:660-826-2380
Mailing Address - Fax:660-827-6277
Practice Address - Street 1:121 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5800
Practice Address - Country:US
Practice Address - Phone:660-826-2380
Practice Address - Fax:660-827-6277
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2014001332103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical