Provider Demographics
NPI:1821138470
Name:KYLE FULLER APRN LLC
Entity Type:Organization
Organization Name:KYLE FULLER APRN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-207-8160
Mailing Address - Street 1:19 S WALNUT ST. STE C
Mailing Address - Street 2:P. O. BOX 530
Mailing Address - City:WAUREGAN
Mailing Address - State:CT
Mailing Address - Zip Code:06387
Mailing Address - Country:US
Mailing Address - Phone:860-207-8160
Mailing Address - Fax:860-207-8170
Practice Address - Street 1:19 S WALNUT ST. STE C
Practice Address - Street 2:
Practice Address - City:WAUREGAN
Practice Address - State:CT
Practice Address - Zip Code:06387
Practice Address - Country:US
Practice Address - Phone:860-207-8160
Practice Address - Fax:860-207-8170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002043364SF0001X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty