Provider Demographics
NPI:1457961534
Name:FULLER, IKEYLA
Entity Type:Individual
Prefix:MISS
First Name:IKEYLA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2057 S ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-1348
Mailing Address - Country:US
Mailing Address - Phone:323-318-2520
Mailing Address - Fax:323-318-2523
Practice Address - Street 1:6130 VINELAND AVE
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-4914
Practice Address - Country:US
Practice Address - Phone:818-766-8161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner