Provider Demographics
NPI:1649872201
Name:FULLER, DONALD V (PHD, ATC, LAT)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:V
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHD, ATC, LAT
Other - Prefix:
Other - First Name:DONALD
Other - Middle Name:V
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, ATC, LAT
Mailing Address - Street 1:310 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906-1499
Mailing Address - Country:US
Mailing Address - Phone:678-221-7963
Mailing Address - Fax:
Practice Address - Street 1:310 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-1499
Practice Address - Country:US
Practice Address - Phone:606-546-1509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT16082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer