1619614930 NPI number — MS. TAMMY LYNN FULLER APRN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619614930 NPI number — MS. TAMMY LYNN FULLER APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER
Provider First Name:
TAMMY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLER
Provider Other First Name:
TAMMY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619614930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
161 N. CAUSEWAY STE. C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW SMYRNA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-424-8440
Provider Business Mailing Address Fax Number:
386-426-8839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
161 N. CAUSEWAY STE. C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW SMYRNA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-424-8440
Provider Business Practice Location Address Fax Number:
386-426-8839
Provider Enumeration Date:
05/18/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  11018505 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 117551100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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