Healthcare Provider Details

I. General information

NPI: 1578299442
Provider Name (Legal Business Name): ABBIE JO FULLER OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ABBIE JO MEESEK

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4429 E 56TH ST
DAVENPORT IA
52807-2995
US

IV. Provider business mailing address

4429 E 56TH ST
DAVENPORT IA
52807-2995
US

V. Phone/Fax

Practice location:
  • Phone: 563-441-3000
  • Fax: 563-441-3020
Mailing address:
  • Phone: 563-441-3000
  • Fax: 563-441-3020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number119150
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: