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General NPI Number Information
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NPI Number | 1598609414
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Entity Type | Individual
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Provider Name | KELLY DAWN FULLER
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Gender | Female
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Dates
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Enumeration Date | 04/20/2026
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Last Update Date | 04/20/2026
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Provider Practice Location Address
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Address Line | 4498 POTOMAC HIGHLANDS TRL
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City | GREEN BANK
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State | WV
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Zip | 24944-8514
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Country | US
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Telephone | 304-456-5115
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Fax | 855-435-1142
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Provider Business Mailing Address
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Address Line | 5384 STAUNTON PARKERSBURG TPKE
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City | BARTOW
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State | WV
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Zip | 24920-8043
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Country | US
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Telephone | 304-517-8108
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State | WV
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