Provider Demographics
NPI:1225660491
Name:FULLARD, NICOLE SHUPE (NP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:SHUPE
Last Name:FULLARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 EVELYN DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31523-1111
Mailing Address - Country:US
Mailing Address - Phone:912-275-7500
Mailing Address - Fax:
Practice Address - Street 1:1111 GLYNCO PKWY STE 10
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-7930
Practice Address - Country:US
Practice Address - Phone:912-264-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN231483363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily