Provider Demographics
NPI:1043218126
Name:FULTON, KIMBERLEY ANN (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:ANN
Last Name:FULTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:ANN
Other - Last Name:HERZBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1445 SHELDON RD STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2479
Mailing Address - Country:US
Mailing Address - Phone:616-296-1500
Mailing Address - Fax:616-296-1502
Practice Address - Street 1:1445 SHELDON RD STE 300
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2479
Practice Address - Country:US
Practice Address - Phone:616-296-1500
Practice Address - Fax:616-296-1502
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P27956Medicare UPIN