Basic Information
| Provider Information | |||||||||
| NPI: | 1700484946 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | KERI | ||||||||
| MiddleName: | ROSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2527 BROAD AVE APT 1 | ||||||||
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| City: | ALTOONA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166011912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245999091 | ||||||||
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| Practice Location | |||||||||
| Address1: | 620 HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | ALTOONA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166014804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148892011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2020 | ||||||||
| LastUpdateDate: | 10/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP022438 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.