MEDICARE: CHALLEY FULLAGAR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	3235	KS

General Provider Information

NPI Number	:	1679971717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHALLEY FULLAGAR

Provider Business Mailing Address
First Line	:	123 N EISENHOWER DR
Second Line	:
City	:	JUNCTION CITY
State	:	KS
Zip	:	66441-3313
Country	:	US
Telephone Number	:	785-717-4130
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 N EISENHOWER DR
Second Line	:
City	:	JUNCTION CITY
State	:	KS
Zip	:	66441-3313
Country	:	US
Telephone Number	:	785-717-4130
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2014
Last Update Date	:	12/05/2014

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Directions to “ CHALLEY FULLAGAR ” Practice Location

Language	Start Address	Practice Location

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