Provider Demographics
NPI:1043218126
Name:FULTON, KIMBERLEY ANN (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:ANN
Last Name:FULTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:ANN
Other - Last Name:HERZBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:600 PARK AVE
Mailing Address - Street 2:600 PARK AVENUE
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2173
Mailing Address - Country:US
Mailing Address - Phone:616-847-8700
Mailing Address - Fax:616-847-1049
Practice Address - Street 1:600 PARK AVE
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2173
Practice Address - Country:US
Practice Address - Phone:616-847-8700
Practice Address - Fax:616-847-1049
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P27956Medicare UPIN