Healthcare Provider Details

I. General information

NPI: 1164196366
Provider Name (Legal Business Name): MELISSA LEE FULLMER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10724 FENCIK LN SW
ALBUQUERQUE NM
87121-3694
US

IV. Provider business mailing address

10724 FENCIK LN SW
ALBUQUERQUE NM
87121-3694
US

V. Phone/Fax

Practice location:
  • Phone: 505-238-6881
  • Fax:
Mailing address:
  • Phone: 505-238-6881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7838
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: