Provider Demographics
NPI:1952544017
Name:FULLER, KELLI M (ANP-BC)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:M
Last Name:FULLER
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:M
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 CLAIBORNE PLACE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119
Mailing Address - Country:US
Mailing Address - Phone:314-920-9517
Mailing Address - Fax:
Practice Address - Street 1:802 MEL CARNAHAN DR STE 215
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:MO
Practice Address - Zip Code:63050
Practice Address - Country:US
Practice Address - Phone:636-543-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-18
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-003174163W00000X
MO131425163W00000X, 363LA2200X
FL2533252163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse