Provider Demographics
NPI:1811752637
Name:FULTINEER, KELLAN FINN
Entity type:Individual
Prefix:
First Name:KELLAN
Middle Name:FINN
Last Name:FULTINEER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KELLAN
Other - Middle Name:RICHARD
Other - Last Name:MERICLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:332 COTTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-1914
Mailing Address - Country:US
Mailing Address - Phone:304-320-1601
Mailing Address - Fax:
Practice Address - Street 1:105 PLATINUM DR STE D
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-2004
Practice Address - Country:US
Practice Address - Phone:304-622-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant