Healthcare Provider Details

I. General information

NPI: 1588194682
Provider Name (Legal Business Name): ASHLEY ANGELA FULLERTON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 PEACHTREE RD NW
ATLANTA GA
30309-1281
US

IV. Provider business mailing address

1984 PEACHTREE RD NW STE 505
ATLANTA GA
30309-5219
US

V. Phone/Fax

Practice location:
  • Phone: 404-605-5000
  • Fax:
Mailing address:
  • Phone: 404-352-1409
  • Fax: 404-352-8176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number008363
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: