Healthcare Provider Details

I. General information

NPI: 1205755295
Provider Name (Legal Business Name): MAI FUJIMOTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 GEORGIA AVE STE B
STATESBORO GA
30458-5590
US

IV. Provider business mailing address

450 GEORGIA AVE STE B
STATESBORO GA
30458-5590
US

V. Phone/Fax

Practice location:
  • Phone: 912-871-2200
  • Fax:
Mailing address:
  • Phone: 912-871-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN-NP258499
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: