Provider Demographics
NPI:1306732326
Name:FULLWOOD, NYASHA
Entity type:Individual
Prefix:MS
First Name:NYASHA
Middle Name:
Last Name:FULLWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 GLENKIRK PL
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-9282
Mailing Address - Country:US
Mailing Address - Phone:919-830-4153
Mailing Address - Fax:
Practice Address - Street 1:8521 SIX FORKS RD STE 350
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5863
Practice Address - Country:US
Practice Address - Phone:919-676-3118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician