Provider Demographics
NPI:1467539783
Name:FULLER, TEIA SQUIRES (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:TEIA
Middle Name:SQUIRES
Last Name:FULLER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32709
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930-2709
Mailing Address - Country:US
Mailing Address - Phone:865-558-6484
Mailing Address - Fax:865-584-4037
Practice Address - Street 1:8904 CROSS PARK DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4703
Practice Address - Country:US
Practice Address - Phone:865-690-2671
Practice Address - Fax:865-690-6445
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5293225100000X
TN8082225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3650210Medicaid
TN4214519OtherBLUE CROSS BLUE SHIELD OF TN
TNCH4394OtherMEDICARE RAILROAD GROUP
TNCH4394OtherMEDICARE RAILROAD GROUP