Provider Demographics
NPI:1871882050
Name:FULWIDER, VICKIE LORRAINE
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:LORRAINE
Last Name:FULWIDER
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 1:591 SENECA CT SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-2648
Mailing Address - Country:US
Mailing Address - Phone:404-447-7939
Mailing Address - Fax:
Practice Address - Street 1:591 SENECA CT SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-2648
Practice Address - Country:US
Practice Address - Phone:404-447-7939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049845500347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle