Provider Demographics
NPI:1073242095
Name:FULLER, NICOLE PAIGE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:PAIGE
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 ROCK HILL CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4883
Mailing Address - Country:US
Mailing Address - Phone:803-341-1722
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:803-341-1722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13814207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine