Provider Demographics
NPI:1841243318
Name:FEDULLO, JANET I (CNM)
Entity Type:Individual
Prefix:MRS
First Name:JANET
Middle Name:I
Last Name:FEDULLO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MRS
Other - First Name:JANET
Other - Middle Name:I
Other - Last Name:FEDULLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1360 UPPER HEMBREE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1230
Mailing Address - Country:US
Mailing Address - Phone:770-817-1970
Mailing Address - Fax:770-817-1980
Practice Address - Street 1:1360 UPPER HEMBREE RD STE 101
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1230
Practice Address - Country:US
Practice Address - Phone:770-817-1970
Practice Address - Fax:770-817-1980
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12027367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN621178892OtherTAX ID