Healthcare Provider Details

I. General information

NPI: 1699488866
Provider Name (Legal Business Name): ERICA FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JO FULLER

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE RD
TRIPLER AMC HI
96859-5001
US

IV. Provider business mailing address

1 JARRETT WHITE RD
TRIPLER AMC HI
96859-5001
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-2474
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number1699488866
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: