Individual
OMAR KEVIN FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
487 THOMAS DR, LOGANVILLE, GA 30052-7262
(973) 572-8260
Mailing address
487 THOMAS DR, LOGANVILLE, GA 30052-7262
(973) 572-8260
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
RN264780
GA
Other
Enumeration date
07/14/2022
Last updated
07/14/2022
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