Provider Demographics
NPI:1497116669
Name:FULCHER, TALISHA M (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:MRS
First Name:TALISHA
Middle Name:M
Last Name:FULCHER
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 HIGHWAY 138 SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-1297
Mailing Address - Country:US
Mailing Address - Phone:770-761-9908
Mailing Address - Fax:
Practice Address - Street 1:1540 HIGHWAY 138 SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1297
Practice Address - Country:US
Practice Address - Phone:770-761-9908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACOA010277224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist