Provider Demographics
NPI:1982564019
Name:FULLER, DEANNA DENISE
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:DENISE
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 YAKIMA AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4851
Mailing Address - Country:US
Mailing Address - Phone:253-396-5246
Mailing Address - Fax:253-779-8665
Practice Address - Street 1:610 YAKIMA AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4851
Practice Address - Country:US
Practice Address - Phone:253-396-5246
Practice Address - Fax:253-779-8665
Is Sole Proprietor?:No
Enumeration Date:2025-11-12
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACM61551872172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker