Provider Demographics
NPI:1023237120
Name:FULLER, RANDELLE K (MPT)
Entity type:Individual
Prefix:
First Name:RANDELLE
Middle Name:K
Last Name:FULLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 W GAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-8113
Mailing Address - Country:US
Mailing Address - Phone:509-586-2828
Mailing Address - Fax:509-783-5438
Practice Address - Street 1:15 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-6371
Practice Address - Country:US
Practice Address - Phone:509-582-6335
Practice Address - Fax:509-582-6375
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA339545OtherL&I
WA2043848Medicaid
WA2043848Medicaid