Provider Demographics
NPI:1225493646
Name:FULLER, RONALD KEITH JR (AG-ACNP)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:KEITH
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1306 WESTCHESTER RDG NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2482
Mailing Address - Country:US
Mailing Address - Phone:770-265-5709
Mailing Address - Fax:404-688-6351
Practice Address - Street 1:80 JESSE HILL DRIVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303
Practice Address - Country:US
Practice Address - Phone:404-251-8921
Practice Address - Fax:404-688-6351
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN176821363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care