Provider Demographics
NPI:1619614930
Name:FULLER, TAMMY LYNN
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:LYNN
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:LYNN
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:14537 WISHING WIND WAY
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6210
Mailing Address - Country:US
Mailing Address - Phone:863-221-8229
Mailing Address - Fax:
Practice Address - Street 1:6376 PINE RIDGE RD UNIT 180
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-3926
Practice Address - Country:US
Practice Address - Phone:239-263-0849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11018505363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily