Provider Demographics
NPI:1639399066
Name:FULLER, TOMEKA BONSHELL (LPN)
Entity Type:Individual
Prefix:
First Name:TOMEKA
Middle Name:BONSHELL
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 WINN WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030
Mailing Address - Country:US
Mailing Address - Phone:404-294-3762
Mailing Address - Fax:404-508-7752
Practice Address - Street 1:440 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1715
Practice Address - Country:US
Practice Address - Phone:404-294-3762
Practice Address - Fax:404-508-7752
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN068949164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse