Provider Demographics
NPI:1619576303
Name:FULLER, ROBERT WAYNE JR (LMT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WAYNE
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 STARFALL DR
Mailing Address - Street 2:
Mailing Address - City:CEDARCREEK
Mailing Address - State:MO
Mailing Address - Zip Code:65627-4203
Mailing Address - Country:US
Mailing Address - Phone:660-270-4048
Mailing Address - Fax:
Practice Address - Street 1:7211 NW 83RD ST STE 207D
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64152-6022
Practice Address - Country:US
Practice Address - Phone:816-482-1695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005017920225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist