Provider Demographics
NPI:1912017435
Name:FULLER, ERICKA K (CFNP)
Entity Type:Individual
Prefix:MISS
First Name:ERICKA
Middle Name:K
Last Name:FULLER
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 469
Mailing Address - Street 2:
Mailing Address - City:ERIN
Mailing Address - State:TN
Mailing Address - Zip Code:37061
Mailing Address - Country:US
Mailing Address - Phone:931-289-4201
Mailing Address - Fax:931-289-4204
Practice Address - Street 1:4891 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:ERIN
Practice Address - State:TN
Practice Address - Zip Code:37061
Practice Address - Country:US
Practice Address - Phone:931-289-4201
Practice Address - Fax:931-289-4204
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN6883363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3648764Medicaid
TN3648764Medicaid
TN3648764Medicare ID - Type Unspecified