Healthcare Provider Details

I. General information

NPI: 1891048765
Provider Name (Legal Business Name): AMANDA RUTH FULLER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3493 VETERANS DR N STE C
HUNTINGDON TN
38344-6230
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 731-986-2933
  • Fax: 731-986-2938
Mailing address:
  • Phone: 901-226-4003
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17089
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: