Provider Demographics
NPI:1700484946
Name:FULTON, KERI ROSE
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:ROSE
Last Name:FULTON
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 1:2527 BROAD AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-1912
Mailing Address - Country:US
Mailing Address - Phone:724-599-9091
Mailing Address - Fax:
Practice Address - Street 1:620 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4804
Practice Address - Country:US
Practice Address - Phone:814-889-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-10
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022438363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner