Healthcare Provider Details

I. General information

NPI: 1649260357
Provider Name (Legal Business Name): JENNIFER FULTON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER KEARNEY PA

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 SILLS RD
E PATCHOGUE NY
11772-4869
US

IV. Provider business mailing address

951 ROANOKE AVE
RIVERHEAD NY
11901-2724
US

V. Phone/Fax

Practice location:
  • Phone: 631-447-8300
  • Fax:
Mailing address:
  • Phone: 631-727-7773
  • Fax: 631-727-7832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number009370
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: