Omar Kevin Fuller

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

RN264780 Issued in GA

Practice address

487 Thomas Dr
Loganville, GA 30052-7262

Phone

(973) 572-8260

NPI assigned

Jul 14, 2022

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in GA, FL2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 2

Specialty

Nurse Practitioner

Education

Other, 2022

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Highland Rivers Community Service BoardGroup PAC ID 9032000245, 57 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Healthy Minds and Wellness

  • Psychiatric/Mental Health Nurse Practitioner
  • Snellville, GA
  • NPI 1043020662

  FL

  Medicare reassignment NPD Authorized official
• Highland Rivers Community Service Board

  • Community/Behavioral Health Agency
  • Dalton, GA
  • NPI 1447256243
  Medicare reassignment Care Compare group NPD
• Mental Health Specialty Group PA

  • Mental Health Counselor
  • Durham, NC
  • NPI 1801472634

  GA

  Medicare reassignment NPD
• Highland Rivers CSB

  • Community/Behavioral Health Agency
  • Dalton, GA
  • NPI 1164585543
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1657756800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1657756800000",
    "number": "1932833050",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "487 THOMAS DR",
            "city": "LOGANVILLE",
            "state": "GA",
            "postal_code": "300527262",
            "telephone_number": "973-572-8260"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "487 THOMAS DR",
            "city": "LOGANVILLE",
            "state": "GA",
            "postal_code": "300527262",
            "telephone_number": "973-572-8260"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FULLER",
        "first_name": "OMAR",
        "middle_name": "KEVIN",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2022-07-14",
        "last_updated": "2022-07-14",
        "certification_date": "2022-07-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "GA",
            "license": "RN264780",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Fresenius Medical Care Loganville, LLC
• Adam Frey
• Alvin Lewis Frey, O.D.
• Stacy W Froelich, LCSW
• Angel Mawuena Fugar, CPNP-PC
• Antoinette Gabriel
• Dana Marie Gallegos, PT
• Kendra Vanice Gamble-Webb, M.D.
• Preston Gantt, MD, SA-C
• Gardenia Home Care Services, L.L.C

• Psychiatric/Mental Health Nurse Practitioner in Loganville, GA
• Providers in Loganville, GA by specialty
• Psychiatric/Mental Health Nurse Practitioner in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 14, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.