Provider Demographics
NPI:1356130165
Name:FULLEM, KELSEY MARIE (RBT)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:FULLEM
Suffix:
Gender:
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 CHERRYSTONE WALK
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2379
Mailing Address - Country:US
Mailing Address - Phone:706-531-4152
Mailing Address - Fax:
Practice Address - Street 1:4319 S LEE ST STE 200
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-5752
Practice Address - Country:US
Practice Address - Phone:678-288-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-24-339565247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other