Provider Demographics
NPI:1245921345
Name:FULLER, KAYLA RAE (LPTA)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:RAE
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 INDEPENDENCE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6200
Mailing Address - Country:US
Mailing Address - Phone:757-917-5061
Mailing Address - Fax:757-904-1821
Practice Address - Street 1:1944 CENTERVILLE TPKE STE 101
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-6839
Practice Address - Country:US
Practice Address - Phone:757-271-4585
Practice Address - Fax:833-627-5148
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306606334225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty