Provider Demographics
NPI:1316471378
Name:FULLER, TAYLOR (CRNA)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:HENSLEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2505 GIFFORD RD
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-7504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2505 GIFFORD RD
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-7504
Practice Address - Country:US
Practice Address - Phone:501-467-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC003195367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered