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NPI Code Detail

MEDICARE: MRS. KELLY SUE FULLER L.P.C.

MEDICARE: MRS. KELLY SUE FULLER L.P.C.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YP2500XProfessional Counselor4184NC
2101YP2500XProfessional Counselor0701003292VA

General Provider Information

NPI Number : 1871614115
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KELLY SUE FULLER L.P.C.
Provider Business Mailing Address
First Line : 310 FLAX MILL WAY
Second Line :
City : CHESAPEAKE
State : VA
Zip : 23322-5893
Country : US
Telephone Number : 757-419-1726
Fax Number : 757-419-1726
Provider Business Practice Location Address
First Line : 1545 CROSSWAYS BLVD STE 250
Second Line :
City : CHESAPEAKE
State : VA
Zip : 23320-0218
Country : US
Telephone Number : 757-419-1726
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/03/2007
Last Update Date : 04/22/2024

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