Healthcare Provider Details

I. General information

NPI: 1801989090
Provider Name (Legal Business Name): JOSEPH FULTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MEMORIAL DRIVE
DALTON GA
30720
US

IV. Provider business mailing address

3104 BLUE LAKE DRIVE SUITE 110
BIRMINGHAM AL
35243
US

V. Phone/Fax

Practice location:
  • Phone: 205-977-1949
  • Fax: 706-226-2283
Mailing address:
  • Phone: 205-977-1949
  • Fax: 205-977-1933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN110452
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: