Provider Demographics
NPI:1518621093
Name:FULLERTON, KELSEY LYNN (AGACNP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5570 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-3583
Mailing Address - Country:US
Mailing Address - Phone:989-583-0100
Mailing Address - Fax:
Practice Address - Street 1:5570 STATE ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-3583
Practice Address - Country:US
Practice Address - Phone:989-583-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2021086004363LA2100X
IN71012272A363LG0600X
MI4704344689363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology