Healthcare Provider Details

I. General information

NPI: 1598609414
Provider Name (Legal Business Name): KELLY DAWN FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4498 POTOMAC HIGHLANDS TRL
GREEN BANK WV
24944-8514
US

IV. Provider business mailing address

5384 STAUNTON PARKERSBURG TPKE
BARTOW WV
24920-8043
US

V. Phone/Fax

Practice location:
  • Phone: 304-456-5115
  • Fax: 855-435-1142
Mailing address:
  • Phone: 304-517-8108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: