Healthcare Provider Details

I. General information

NPI: 1336043447
Provider Name (Legal Business Name): TANNER FULLER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TANNER FULLER RN

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HOSPITAL DR
MACON GA
31217-3838
US

IV. Provider business mailing address

647 SPARTA HWY
EATONTON GA
31024-8371
US

V. Phone/Fax

Practice location:
  • Phone: 478-765-4820
  • Fax:
Mailing address:
  • Phone: 706-623-1034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN317387
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: