Provider Demographics
NPI:1013320548
Name:FULLER, TAMARA (RN)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TAMI
Other - Middle Name:
Other - Last Name:BORAWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1926 BAILEY RD
Mailing Address - Street 2:
Mailing Address - City:NORTHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:43619-2302
Mailing Address - Country:US
Mailing Address - Phone:419-779-4344
Mailing Address - Fax:
Practice Address - Street 1:1926 BAILEY RD
Practice Address - Street 2:
Practice Address - City:NORTHWOOD
Practice Address - State:OH
Practice Address - Zip Code:43619-2302
Practice Address - Country:US
Practice Address - Phone:419-779-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH375058163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse