Provider Demographics
NPI:1275740540
Name:FUSSELL, TONI BROOKE
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:BROOKE
Last Name:FUSSELL
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 1:464 SYLVIS RD
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-6042
Mailing Address - Country:US
Mailing Address - Phone:615-326-0218
Mailing Address - Fax:
Practice Address - Street 1:104 HIGHWAY 70 E
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2034
Practice Address - Country:US
Practice Address - Phone:615-446-5585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14109183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician