Provider Demographics
NPI:1639795180
Name:FULLER, TARA RAQUEL (APRN, MSN)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:RAQUEL
Last Name:FULLER
Suffix:
Gender:F
Credentials:APRN, MSN
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:RAQUEL
Other - Last Name:LISTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:914 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ARGYLE
Mailing Address - State:TX
Mailing Address - Zip Code:76226-2503
Mailing Address - Country:US
Mailing Address - Phone:940-464-7222
Mailing Address - Fax:940-464-7220
Practice Address - Street 1:914 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ARGYLE
Practice Address - State:TX
Practice Address - Zip Code:76226-2503
Practice Address - Country:US
Practice Address - Phone:866-625-2279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-21
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1018810363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily