Basic Information
| Provider Information | |||||||||
| NPI: | 1225660491 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLARD | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | SHUPE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 EVELYN DR | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315231111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122757500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 GLYNCO PKWY STE 10 | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315257930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122649111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2020 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN231483 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.