Provider Demographics
NPI:1295722973
Name:NELSON, TARRA MCCULLAR (NP-C)
Entity type:Individual
Prefix:
First Name:TARRA
Middle Name:MCCULLAR
Last Name:NELSON
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 1:1400 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:STE 250
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7668
Mailing Address - Country:US
Mailing Address - Phone:770-889-7118
Mailing Address - Fax:770-844-7835
Practice Address - Street 1:1400 NORTHSIDE FORSYTH DR
Practice Address - Street 2:STE 250
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7668
Practice Address - Country:US
Practice Address - Phone:770-889-7118
Practice Address - Fax:770-844-7835
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN112198363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000806979HMedicaid
GA000806979IMedicaid
GA000806979JMedicaid
GA202I504820Medicare PIN
GA05BBHKKMedicare PIN
GA000806979HMedicaid