Provider Demographics
NPI:1619297058
Name:FULLER, LINDA KAY (NP)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:KAY
Last Name:FULLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 GATES AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-4304
Mailing Address - Country:US
Mailing Address - Phone:347-424-4799
Mailing Address - Fax:347-238-3674
Practice Address - Street 1:1102 GATES AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-4304
Practice Address - Country:US
Practice Address - Phone:347-424-4799
Practice Address - Fax:347-238-3674
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY526438-1163W00000X
NYF405928-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse