Provider Demographics
NPI:1841049194
Name:FULLWOOD, TALEITHA
Entity type:Individual
Prefix:
First Name:TALEITHA
Middle Name:
Last Name:FULLWOOD
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 GREEN VALLEY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7096
Mailing Address - Country:US
Mailing Address - Phone:800-883-5170
Mailing Address - Fax:
Practice Address - Street 1:701 GREEN VALLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7096
Practice Address - Country:US
Practice Address - Phone:800-883-5170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP9C8R6J6246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy