Provider Demographics
NPI:1720779663
Name:FULTON, KENYA
Entity Type:Individual
Prefix:
First Name:KENYA
Middle Name:
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 1:1041 MONTEREY CT
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60484-3236
Mailing Address - Country:US
Mailing Address - Phone:708-664-1250
Mailing Address - Fax:
Practice Address - Street 1:931 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-1542
Practice Address - Country:US
Practice Address - Phone:833-534-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle