Provider Demographics
NPI:1891048765
Name:FULLER, AMANDA RUTH (FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RUTH
Last Name:FULLER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3493 VETERANS DR N STE C
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-6230
Mailing Address - Country:US
Mailing Address - Phone:731-986-2933
Mailing Address - Fax:731-986-2938
Practice Address - Street 1:3493 VETERANS DR N STE C
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-6230
Practice Address - Country:US
Practice Address - Phone:731-986-2933
Practice Address - Fax:731-986-2938
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000017089363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ001034Medicaid
TNQ054963Medicaid