Healthcare Provider Details

I. General information

NPI: 1316471378
Provider Name (Legal Business Name): TAYLOR FULLER C.R.N.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAYLOR HENSLEE C.R.N.A.

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 GIFFORD RD
MALVERN AR
72104-7504
US

IV. Provider business mailing address

2505 GIFFORD RD
MALVERN AR
72104-7504
US

V. Phone/Fax

Practice location:
  • Phone: 501-467-2404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC003195
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: