Provider Demographics
NPI:1245493329
Name:FULLNER, KYLIE JEANNINE (DPT)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:JEANNINE
Last Name:FULLNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1415
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:NE
Mailing Address - Zip Code:68748-1415
Mailing Address - Country:US
Mailing Address - Phone:402-310-2006
Mailing Address - Fax:
Practice Address - Street 1:325 N SAINT PAUL ST
Practice Address - Street 2:SUITE 4200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-3801
Practice Address - Country:US
Practice Address - Phone:866-953-0011
Practice Address - Fax:866-953-0012
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009346225100000X
KS1103936225100000X
NE2736225100000X
TX1186306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist