Provider Demographics
NPI:1639786932
Name:FULLER, MELODY RENE
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:RENE
Last Name:FULLER
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 1:520 INNER BANKS RD
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29316-6170
Mailing Address - Country:US
Mailing Address - Phone:864-541-9363
Mailing Address - Fax:
Practice Address - Street 1:744 ARDEN LN STE 200
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3287
Practice Address - Country:US
Practice Address - Phone:803-787-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23579363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner