Provider Demographics
NPI:1063852630
Name:FULLER, CHRISTY LATASHA (LMT)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTY
Middle Name:LATASHA
Last Name:FULLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2759 DELK RD SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8847
Mailing Address - Country:US
Mailing Address - Phone:404-343-8848
Mailing Address - Fax:
Practice Address - Street 1:2288 MIRIAM LN
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-5551
Practice Address - Country:US
Practice Address - Phone:404-343-8848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT008977302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization