Provider Demographics
NPI:1043723133
Name:FULLER, KEYONNA DENAY
Entity Type:Individual
Prefix:
First Name:KEYONNA
Middle Name:DENAY
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 N HARDING RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-1525
Mailing Address - Country:US
Mailing Address - Phone:614-743-5631
Mailing Address - Fax:614-340-3096
Practice Address - Street 1:195 N HARDING RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-1525
Practice Address - Country:US
Practice Address - Phone:614-743-5631
Practice Address - Fax:614-340-3096
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-10
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No376K00000XNursing Service Related ProvidersNurse's Aide