Provider Demographics
NPI:1053855809
Name:FULLER, KEYDELLA (APN)
Entity type:Individual
Prefix:
First Name:KEYDELLA
Middle Name:
Last Name:FULLER
Suffix:
Gender:
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ANGELA DR
Mailing Address - Street 2:STE 202
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857
Mailing Address - Country:US
Mailing Address - Phone:732-908-4522
Mailing Address - Fax:
Practice Address - Street 1:UF HEALTH
Practice Address - Street 2:15255 MAX LEGGETT PARKWAY, SUITE 3600
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218
Practice Address - Country:US
Practice Address - Phone:904-383-1011
Practice Address - Fax:904-383-1411
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00692900363LF0000X
FL11012620363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily