Provider Demographics
NPI:1962737940
Name:FULLER, KEVIN POWELL I
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:POWELL
Last Name:FULLER
Suffix:I
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:KEVIN
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1839 ZARKER ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1351
Mailing Address - Country:US
Mailing Address - Phone:717-379-2546
Mailing Address - Fax:
Practice Address - Street 1:1839 ZARKER ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1351
Practice Address - Country:US
Practice Address - Phone:717-379-2546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA271077801374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA271077801Medicaid