Healthcare Provider Details

I. General information

NPI: 1972307130
Provider Name (Legal Business Name): MELINDA ANNE FULLER
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2025
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 SIBLEY CT
COLUMBIA MO
65203-9766
US

IV. Provider business mailing address

5301 SIBLEY CT
COLUMBIA MO
65203-9766
US

V. Phone/Fax

Practice location:
  • Phone: 573-999-0464
  • Fax:
Mailing address:
  • Phone: 573-999-0464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number104970
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: