Healthcare Provider Details

I. General information

NPI: 1235024951
Provider Name (Legal Business Name): COURTNEY FULLER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 SOUTHERN DR
STATESBORO GA
30460-1360
US

IV. Provider business mailing address

1332 SOUTHERN DR
STATESBORO GA
30460-1360
US

V. Phone/Fax

Practice location:
  • Phone: 912-901-7489
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN264235
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: