Provider Demographics
NPI:1326590597
Name:WALULAK, KYLIE FULLER
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:FULLER
Last Name:WALULAK
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 1:258 OLD LYMAN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01075-2653
Mailing Address - Country:US
Mailing Address - Phone:413-532-3280
Mailing Address - Fax:
Practice Address - Street 1:258 OLD LYMAN RD
Practice Address - Street 2:
Practice Address - City:SOUTH HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01075-2653
Practice Address - Country:US
Practice Address - Phone:413-532-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker