Provider Demographics
NPI:1619614930
Name:FULLER, TAMMY LYNN (APRN)
Entity type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:LYNN
Last Name:FULLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:LYNN
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:161 N. CAUSEWAY STE. C
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169
Mailing Address - Country:US
Mailing Address - Phone:386-424-8440
Mailing Address - Fax:386-426-8839
Practice Address - Street 1:161 N. CAUSEWAY STE. C
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169
Practice Address - Country:US
Practice Address - Phone:386-424-8440
Practice Address - Fax:386-426-8839
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11018505363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily