Provider Demographics
NPI:1114696481
Name:FULFORD, TERESA R
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:R
Last Name:FULFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 BARSHAY DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-0961
Mailing Address - Country:US
Mailing Address - Phone:404-904-2370
Mailing Address - Fax:
Practice Address - Street 1:75 BARSHAY DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-0961
Practice Address - Country:US
Practice Address - Phone:404-904-2370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744R1103XOther Service ProvidersSpecialistResearch Data Abstracter/CoderGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty