Healthcare Provider Details

I. General information

NPI: 1225493646
Provider Name (Legal Business Name): RONALD KEITH FULLER JR. AG-ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE
ATLANTA GA
30308-2212
US

IV. Provider business mailing address

1306 WESTCHESTER RDG NE
ATLANTA GA
30329-2482
US

V. Phone/Fax

Practice location:
  • Phone: 404-686-2271
  • Fax:
Mailing address:
  • Phone: 770-265-5709
  • Fax: 404-688-6351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN176821
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: