Healthcare Provider Details

I. General information

NPI: 1619297058
Provider Name (Legal Business Name): LINDA KAY FULLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 GATES AVE
BROOKLYN NY
11221-4304
US

IV. Provider business mailing address

1102 GATES AVE
BROOKLYN NY
11221-4304
US

V. Phone/Fax

Practice location:
  • Phone: 347-424-4799
  • Fax: 347-238-3674
Mailing address:
  • Phone: 347-424-4799
  • Fax: 347-238-3674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF405928-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number526438-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: