Healthcare Provider Details

I. General information

NPI: 1366910101
Provider Name (Legal Business Name): AMANDA JOY FULLER OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2018
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 CITADEL DR E STE 250
COLORADO SPRINGS CO
80909-5396
US

IV. Provider business mailing address

1129 STANTON ST
COLORADO SPRINGS CO
80907-4677
US

V. Phone/Fax

Practice location:
  • Phone: 719-685-7890
  • Fax:
Mailing address:
  • Phone: 616-648-0301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT.0005616
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: