Provider Demographics
NPI:1659014751
Name:FULTS, HEATHER DANYEL (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DANYEL
Last Name:FULTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S B B KING BLVD # 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:901-436-1381
Mailing Address - Fax:
Practice Address - Street 1:2090 E GEORGIA RD
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388-8936
Practice Address - Country:US
Practice Address - Phone:864-787-3726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-16
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC105463363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program