Basic Information
| Provider Information | |||||||||
| NPI: | 1659014751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULTS | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | DANYEL | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S B B KING BLVD # 100 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014361381 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2090 E GEORGIA RD | ||||||||
| Address2: | |||||||||
| City: | WOODRUFF | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293888936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647873726 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2022 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363L00000X | 105463 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.