=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881491405
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER TORELL FULLWOOD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2025
-----------------------------------------------------
Last Update Date | 03/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2116 STREAMWAY CT
-----------------------------------------------------
City | GWYNN OAK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21207-6093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-712-3904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2116 STREAMWAY CT
-----------------------------------------------------
City | GWYNN OAK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21207-6093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-712-3904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------