Provider Demographics
NPI:1851098347
Name:FULLER-CRAWFORD, JOANNA L (RN)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:L
Last Name:FULLER-CRAWFORD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5228 ROSEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-5113
Mailing Address - Country:US
Mailing Address - Phone:678-834-2285
Mailing Address - Fax:404-445-0347
Practice Address - Street 1:5228 ROSEWOOD PL
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-5113
Practice Address - Country:US
Practice Address - Phone:678-834-2285
Practice Address - Fax:404-445-0347
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN214718163W00000X, 163WC1600X, 163WH0200X, 163WH0500X, 163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WH0500XNursing Service ProvidersRegistered NurseHemodialysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003263865Medicaid