Healthcare Provider Details

I. General information

NPI: 1619614930
Provider Name (Legal Business Name): TAMMY LYNN FULLER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMMY LYNN MILLER APRN

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 N. CAUSEWAY STE. C
NEW SMYRNA BEACH FL
32169
US

IV. Provider business mailing address

161 N. CAUSEWAY STE. C
NEW SMYRNA BEACH FL
32169
US

V. Phone/Fax

Practice location:
  • Phone: 386-424-8440
  • Fax: 386-426-8839
Mailing address:
  • Phone: 386-424-8440
  • Fax: 386-426-8839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11018505
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: