Healthcare Provider Details

I. General information

NPI: 1861884215
Provider Name (Legal Business Name): TEAWKA FULLMORE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 PARKWOOD CIR SE STE 900
ATLANTA GA
30339-2140
US

IV. Provider business mailing address

271 SIMBA LN
WAYCROSS GA
31503-9231
US

V. Phone/Fax

Practice location:
  • Phone: 480-862-1700
  • Fax:
Mailing address:
  • Phone: 912-670-1564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN176193
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN176193
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN176193
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: