Provider Demographics
NPI:1053855809
Name:FULLER, KEYDELLA (APN)
Entity Type:Individual
Prefix:
First Name:KEYDELLA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 RTE 37 W STE 5
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-8011
Mailing Address - Country:US
Mailing Address - Phone:732-608-9737
Mailing Address - Fax:
Practice Address - Street 1:21 ANGELA DR
Practice Address - Street 2:STE 202
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-1986
Practice Address - Country:US
Practice Address - Phone:732-908-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00692900363LF0000X
FL11012620363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily