Provider Demographics
NPI:1003653163
Name:FULSE, SAMANTHA A
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:A
Last Name:FULSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 J NOLAN WELLS RD APT E306
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6854
Mailing Address - Country:US
Mailing Address - Phone:904-250-8491
Mailing Address - Fax:
Practice Address - Street 1:97109 PIRATES POINT RD
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-6533
Practice Address - Country:US
Practice Address - Phone:904-901-1718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0028905888374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide