Basic Information
Provider Information | |||||||||
NPI: | 1710954987 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FULLER | ||||||||
FirstName: | JANET | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JONES | ||||||||
OtherFirstName: | JANET | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2564 | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 31203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787465644 | ||||||||
FaxNumber: | 4787454849 | ||||||||
Practice Location | |||||||||
Address1: | 380 HOSPITAL DRIVE | ||||||||
Address2: | SUITE 410 | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 31217 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787465644 | ||||||||
FaxNumber: | 4787454849 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2006 | ||||||||
LastUpdateDate: | 06/04/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN071940 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 000622146D | 05 | GA |   | MEDICAID | 391033 | 01 | GA | WELLCARE | OTHER | 430022179 | 01 | GA | PALMETTO GBA | OTHER | 000622146F | 05 | GA |   | MEDICAID | 000622146G | 05 | GA |   | MEDICAID | P00410208 | 01 | GA | RAILROAD MEDICARE | OTHER | 000622146E | 05 | GA |   | MEDICAID |