Provider Demographics
NPI:1699480178
Name:FULLER, KRISTIN NICOLE
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:NICOLE
Other - Last Name:CRAMBLET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:296 S FERDON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-3702
Mailing Address - Country:US
Mailing Address - Phone:850-333-1279
Mailing Address - Fax:
Practice Address - Street 1:296 S FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-3702
Practice Address - Country:US
Practice Address - Phone:850-333-1279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician