Provider Demographics
NPI:1629781612
Name:FULLER, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 PINECREST DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:AL
Mailing Address - Zip Code:35117-3335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:619 19TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1900
Practice Address - Country:US
Practice Address - Phone:205-934-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant