Provider Demographics
NPI:1760806111
Name:FULTS, SELVI (NP-C)
Entity Type:Individual
Prefix:
First Name:SELVI
Middle Name:
Last Name:FULTS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2054 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3634
Mailing Address - Country:US
Mailing Address - Phone:478-918-0770
Mailing Address - Fax:478-918-0771
Practice Address - Street 1:1531 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3634
Practice Address - Country:US
Practice Address - Phone:478-599-0110
Practice Address - Fax:478-599-0001
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN167969363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN167969OtherNP LICENSE