Provider Demographics
NPI:1144793407
Name:FULLER, KELLY (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:KLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1007 PATHFINDER WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3243
Mailing Address - Country:US
Mailing Address - Phone:321-507-4033
Mailing Address - Fax:
Practice Address - Street 1:1007 PATHFINDER WAY STE 120
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3243
Practice Address - Country:US
Practice Address - Phone:321-507-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000259363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health