Provider Demographics
NPI:1447941463
Name:FULLER, KENDALL ALEXANDRA
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:ALEXANDRA
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 BOWMAN PARK PT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-1547
Mailing Address - Country:US
Mailing Address - Phone:404-542-2448
Mailing Address - Fax:
Practice Address - Street 1:4950 BOWMAN PARK PT
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-1547
Practice Address - Country:US
Practice Address - Phone:404-542-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANCO-000006363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics