Provider Demographics
NPI:1780348060
Name:FULMER, KIMBERLY TILLMAN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:TILLMAN
Last Name:FULMER
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 1:739 BURTON AVE
Mailing Address - Street 2:
Mailing Address - City:METTER
Mailing Address - State:GA
Mailing Address - Zip Code:30439-3303
Mailing Address - Country:US
Mailing Address - Phone:912-690-2652
Mailing Address - Fax:833-637-2036
Practice Address - Street 1:856 US HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-4984
Practice Address - Country:US
Practice Address - Phone:478-237-7022
Practice Address - Fax:833-637-2036
Is Sole Proprietor?:No
Enumeration Date:2021-10-24
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN139827363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner