Provider Demographics
NPI:1336951367
Name:FULTON, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:FULTON
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 1:650 PONCE DE LEON AVE STE 300
Mailing Address - Street 2:1689
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308
Mailing Address - Country:US
Mailing Address - Phone:678-310-7504
Mailing Address - Fax:
Practice Address - Street 1:650 PONCE DE LEON AVE STE 300
Practice Address - Street 2:1689
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308
Practice Address - Country:US
Practice Address - Phone:678-310-7504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered