Provider Demographics
NPI:1922363829
Name:FULLER, DENISE LYNN (LMT)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:LYNN
Last Name:FULLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14754 SW SCHOLLS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-9113
Mailing Address - Country:US
Mailing Address - Phone:503-358-3385
Mailing Address - Fax:
Practice Address - Street 1:14754 SW SCHOLLS FERRY RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-9113
Practice Address - Country:US
Practice Address - Phone:503-358-3385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-07
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19130225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist