Provider Demographics
NPI:1356977896
Name:FULLER-NG, KEVIN (MS, RD, CSO, CDN)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:FULLER-NG
Suffix:
Gender:M
Credentials:MS, RD, CSO, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 VANDERBILT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:165 VANDERBILT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2521
Practice Address - Country:US
Practice Address - Phone:718-616-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86027416133VN1301X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology