Healthcare Provider Details

I. General information

NPI: 1598224875
Provider Name (Legal Business Name): KYLIE A FULLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BON AIR RD
GREENBRAE CA
94904-1702
US

IV. Provider business mailing address

250 W BONITA AVE STE 100
POMONA CA
91767-1863
US

V. Phone/Fax

Practice location:
  • Phone: 415-925-7591
  • Fax:
Mailing address:
  • Phone: 909-392-2002
  • Fax: 626-795-4768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA187008
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: