Provider Demographics
NPI:1720869316
Name:FULLER, KAYLYN
Entity Type:Individual
Prefix:
First Name:KAYLYN
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 1:125 S COTTAGE ST APT 324
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-6359
Mailing Address - Country:US
Mailing Address - Phone:516-761-0209
Mailing Address - Fax:
Practice Address - Street 1:125 S COTTAGE ST APT 324
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6359
Practice Address - Country:US
Practice Address - Phone:516-761-0209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY618813163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy