Provider Demographics
NPI:1013802305
Name:FULLER, TIANNA JEAN (FNP, MSN)
Entity type:Individual
Prefix:
First Name:TIANNA
Middle Name:JEAN
Last Name:FULLER
Suffix:
Gender:F
Credentials:FNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9898 S GLASGOW DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-9113
Mailing Address - Country:US
Mailing Address - Phone:208-409-5273
Mailing Address - Fax:
Practice Address - Street 1:9898 S GLASGOW DR
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-9113
Practice Address - Country:US
Practice Address - Phone:208-409-5273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9666776-8900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily