Healthcare Provider Details

I. General information

NPI: 1053855809
Provider Name (Legal Business Name): KEYDELLA FULLER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UF HEALTH 15255 MAX LEGGETT PARKWAY, SUITE 3600
JACKSONVILLE FL
32218
US

IV. Provider business mailing address

15255 MAX LEGGETT PKWY STE 3600
JACKSONVILLE FL
32218-7279
US

V. Phone/Fax

Practice location:
  • Phone: 904-383-1011
  • Fax: 904-383-1411
Mailing address:
  • Phone: 904-383-1011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11012620
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00692900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: