Provider Demographics
NPI:1528058385
Name:FULLER, ANDREA J (RN,FNP)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:J
Last Name:FULLER
Suffix:
Gender:F
Credentials:RN,FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 HISTORIC HWY 441 N.
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535
Mailing Address - Country:US
Mailing Address - Phone:706-754-5511
Mailing Address - Fax:706-754-5577
Practice Address - Street 1:590 HISTORIC OLD HWY 441
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535
Practice Address - Country:US
Practice Address - Phone:706-754-5511
Practice Address - Fax:706-754-5577
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA098416363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBCBSMedicare ID - Type Unspecified
GAS48714Medicare UPIN