Individual
MISTINIQUE J FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RN, LMP
Contact information
Practice address
1100 E MAIN ST STE A, OTHELLO, WA 99344-1587
(509) 770-4067
Mailing address
1968 W MUSE RD, OTHELLO, WA 99344-9757
(509) 770-4067
Taxonomy
Speciality
Code
Description
License number
State
163WM1400X
Nurse Massage Therapist (NMT)
Primary
RN60154916
WA
Other
Enumeration date
07/25/2015
Last updated
10/05/2021
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