Healthcare Provider Details

I. General information

NPI: 1821138470
Provider Name (Legal Business Name): KYLE FULLER APRN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 S WALNUT ST. STE C
WAUREGAN CT
06387
US

IV. Provider business mailing address

19 S WALNUT ST. STE C P. O. BOX 530
WAUREGAN CT
06387
US

V. Phone/Fax

Practice location:
  • Phone: 860-207-8160
  • Fax: 860-207-8170
Mailing address:
  • Phone: 860-207-8160
  • Fax: 860-207-8170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number002043
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number002043
License Number StateCT

VIII. Authorized Official

Name: MS. KYLE J FULLER
Title or Position: OWNER/SOLE PROPRIETOR
Credential: APRN
Phone: 860-207-8160