Provider Demographics
NPI:1215095468
Name:STULL, MILDRED POTTER (RN, NP)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:POTTER
Last Name:STULL
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 MCDONOUGH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1524
Mailing Address - Country:US
Mailing Address - Phone:770-775-7861
Mailing Address - Fax:770-775-4478
Practice Address - Street 1:1050 MCDONOUGH RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1524
Practice Address - Country:US
Practice Address - Phone:770-775-7861
Practice Address - Fax:770-775-4478
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN043103363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBKBSMedicare ID - Type Unspecified