Provider Demographics
NPI:1588920524
Name:FULLER, JANA ALLEN (NP)
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:ALLEN
Last Name:FULLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JANA
Other - Middle Name:ALLEN
Other - Last Name:FLOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1445 OLD MCDONOUGH HWY SE
Mailing Address - Street 2:SUITE E
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5977
Mailing Address - Country:US
Mailing Address - Phone:770-922-9222
Mailing Address - Fax:770-922-8794
Practice Address - Street 1:1445 OLD MCDONOUGH HWY SE
Practice Address - Street 2:SUITE E
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5977
Practice Address - Country:US
Practice Address - Phone:770-922-9222
Practice Address - Fax:770-922-8794
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN147639363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner