Provider Demographics
NPI:1225823784
Name:FULLER, NICALER PASHANNA
Entity type:Individual
Prefix:
First Name:NICALER
Middle Name:PASHANNA
Last Name:FULLER
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 1:2645 WILDFLOWER LN
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-4089
Mailing Address - Country:US
Mailing Address - Phone:912-604-3074
Mailing Address - Fax:
Practice Address - Street 1:2645 WILDFLOWER LN
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-4089
Practice Address - Country:US
Practice Address - Phone:912-604-3074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSW012374104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker