Provider Demographics
NPI:1861884215
Name:FULLMORE, TEAWKA (NP-C)
Entity type:Individual
Prefix:MRS
First Name:TEAWKA
Middle Name:
Last Name:FULLMORE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 KNIGHT AVENUE
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-1943
Mailing Address - Country:US
Mailing Address - Phone:912-283-9423
Mailing Address - Fax:912-283-8204
Practice Address - Street 1:711 KNIGHT AVENUE
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-1943
Practice Address - Country:US
Practice Address - Phone:912-283-9423
Practice Address - Fax:912-283-8204
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN176193363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACG6045OtherRAILROAD MEDICARE GROUP ID
GA1144420530OtherMEDICARE GROUP NPI
GA1861884215OtherMEDICARE NPI
GA2025I01375OtherMEDICARE PTAN
RN176193OtherRN STATE LICENSE