Provider Demographics
NPI:1598224875
Name:FULLER, KYLIE A (MD)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:A
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:250 W BONITA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1863
Mailing Address - Country:US
Mailing Address - Phone:909-392-2002
Mailing Address - Fax:626-795-4768
Practice Address - Street 1:250 W BONITA AVE STE 100
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1863
Practice Address - Country:US
Practice Address - Phone:909-392-2002
Practice Address - Fax:626-795-4768
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA187008207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology