Provider Demographics
NPI:1437582426
Name:FULLER, HOLLY PARKS (APN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:PARKS
Last Name:FULLER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:J
Other - Last Name:PARKS FULLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:7714 POPLAR AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3941
Mailing Address - Country:US
Mailing Address - Phone:901-683-0055
Mailing Address - Fax:
Practice Address - Street 1:1727 KIRBY PKWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-8328
Practice Address - Country:US
Practice Address - Phone:901-683-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17636363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner