Provider Demographics
NPI:1174878516
Name:FULLER, MEGAN H (NP)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:H
Last Name:FULLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 DESALES AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1100
Mailing Address - Country:US
Mailing Address - Phone:423-654-7670
Mailing Address - Fax:423-654-7671
Practice Address - Street 1:2515 DESALES AVE STE 204
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1100
Practice Address - Country:US
Practice Address - Phone:423-654-7670
Practice Address - Fax:423-654-7671
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN16867363L00000X
GARN298561363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1530107Medicaid
P01125439OtherRR MEDICARE
TN4331416OtherBCBS
GA003129433CMedicaid
AL143573Medicaid
TN4331416OtherBCBS