Provider Demographics
NPI:1861127946
Name:FULLER, KELLY G (LPN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:G
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PEYTON RD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37144-7753
Mailing Address - Country:US
Mailing Address - Phone:931-675-2343
Mailing Address - Fax:
Practice Address - Street 1:615 WILSON AVE
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3264
Practice Address - Country:US
Practice Address - Phone:931-455-9369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN95880164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse