Healthcare Provider Details

I. General information

NPI: 1881491405
Provider Name (Legal Business Name): TYLER TORELL FULLWOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2025
Last Update Date: 03/01/2025
Certification Date: 03/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 STREAMWAY CT
GWYNN OAK MD
21207-6093
US

IV. Provider business mailing address

2116 STREAMWAY CT
GWYNN OAK MD
21207-6093
US

V. Phone/Fax

Practice location:
  • Phone: 443-712-3904
  • Fax:
Mailing address:
  • Phone: 443-712-3904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: