Provider Demographics
NPI:1881491405
Name:FULLWOOD, TYLER TORELL
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:TORELL
Last Name:FULLWOOD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 STREAMWAY CT
Mailing Address - Street 2:
Mailing Address - City:GWYNN OAK
Mailing Address - State:MD
Mailing Address - Zip Code:21207-6093
Mailing Address - Country:US
Mailing Address - Phone:443-712-3904
Mailing Address - Fax:
Practice Address - Street 1:2116 STREAMWAY CT
Practice Address - Street 2:
Practice Address - City:GWYNN OAK
Practice Address - State:MD
Practice Address - Zip Code:21207-6093
Practice Address - Country:US
Practice Address - Phone:443-712-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-01
Last Update Date:2025-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer