Provider Demographics
NPI:1588156715
Name:FULLER, BRANDY ERIN (RD,LD)
Entity type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:ERIN
Last Name:FULLER
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:STUTTGART
Mailing Address - State:AR
Mailing Address - Zip Code:72160-4712
Mailing Address - Country:US
Mailing Address - Phone:501-240-6382
Mailing Address - Fax:
Practice Address - Street 1:1703 N BUERKLE ST
Practice Address - Street 2:
Practice Address - City:STUTTGART
Practice Address - State:AR
Practice Address - Zip Code:72160
Practice Address - Country:US
Practice Address - Phone:870-674-6603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR980133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered