Provider Demographics
NPI:1558765214
Name:FULLER, KAYLA (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:620 JOHN PAUL JONES CIR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23708-2111
Mailing Address - Country:US
Mailing Address - Phone:757-953-4564
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:757-953-4564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00600900363A00000X
AK1177363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant