Provider Demographics
NPI:1700840568
Name:FULLER, WENDY S (NP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:S
Last Name:FULLER
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 1:551 N CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:SOCIAL CIRCLE
Mailing Address - State:GA
Mailing Address - Zip Code:30025-2887
Mailing Address - Country:US
Mailing Address - Phone:678-342-6000
Mailing Address - Fax:678-342-6006
Practice Address - Street 1:551 N CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:SOCIAL CIRCLE
Practice Address - State:GA
Practice Address - Zip Code:30025-2887
Practice Address - Country:US
Practice Address - Phone:678-342-6000
Practice Address - Fax:678-342-6006
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN082682 NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP58277Medicare UPIN
GA50BBKBFMedicare ID - Type UnspecifiedPROVIDER ID