Provider Demographics
NPI:1649415142
Name:FULMER, TARA C (CRNA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:C
Last Name:FULMER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 WILD TIMBER PKWY
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-2534
Mailing Address - Country:US
Mailing Address - Phone:205-337-4438
Mailing Address - Fax:
Practice Address - Street 1:1940 ELMER J BISSELL RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-2941
Practice Address - Country:US
Practice Address - Phone:205-638-4768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-096758367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered