Provider Demographics
NPI:1871384891
Name:FULLER, KANIKA SHAVON (BSN, RN, PED-BC)
Entity type:Individual
Prefix:MS
First Name:KANIKA
Middle Name:SHAVON
Last Name:FULLER
Suffix:
Gender:F
Credentials:BSN, RN, PED-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HOW LN
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-3653
Mailing Address - Country:US
Mailing Address - Phone:732-448-1000
Mailing Address - Fax:
Practice Address - Street 1:123 HOW LN
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-3653
Practice Address - Country:US
Practice Address - Phone:732-448-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO11743500163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics