Provider Demographics
NPI:1861884215
Name:FULLMORE, TEAWKA (NP-C)
Entity type:Individual
Prefix:MS
First Name:TEAWKA
Middle Name:
Last Name:FULLMORE
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 1:271 SIMBA LN
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31503-9231
Mailing Address - Country:US
Mailing Address - Phone:912-670-1564
Mailing Address - Fax:
Practice Address - Street 1:1000 PARKWOOD CIR SE STE 900
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-2140
Practice Address - Country:US
Practice Address - Phone:480-862-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN176193363LG0600X, 363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACG6045OtherRAILROAD MEDICARE GROUP ID
GA1144420530OtherMEDICARE GROUP NPI
GA1861884215OtherMEDICARE NPI
GA2025I01375OtherMEDICARE PTAN
RN176193OtherRN STATE LICENSE