Healthcare Provider Details

I. General information

NPI: 1033717236
Provider Name (Legal Business Name): TANSHA FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8606 N 10TH ST
TAMPA FL
33604-1712
US

IV. Provider business mailing address

8606 N 10TH ST
TAMPA FL
33604-1712
US

V. Phone/Fax

Practice location:
  • Phone: 813-638-4273
  • Fax:
Mailing address:
  • Phone: 813-638-4273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberF46081979620
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: