Provider Demographics
NPI:1992714984
Name:FULLER, WENDY BRANNAN (FNP)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:BRANNAN
Last Name:FULLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3720 DAVINCI COURT
Mailing Address - Street 2:STE 400
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092
Mailing Address - Country:US
Mailing Address - Phone:478-288-6308
Mailing Address - Fax:770-582-4189
Practice Address - Street 1:3720 DAVINCI CT
Practice Address - Street 2:STE 400
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-7627
Practice Address - Country:US
Practice Address - Phone:478-288-6308
Practice Address - Fax:770-582-4189
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN093416363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA894206368FMedicaid
GA894206368FMedicaid