Healthcare Provider Details

I. General information

NPI: 1871418475
Provider Name (Legal Business Name): MOLLY ANNE FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9231B HAMER RD
GEORGETOWN OH
45121-1527
US

IV. Provider business mailing address

4602 PUMPKIN RIDGE RD
WEST UNION OH
45693-8951
US

V. Phone/Fax

Practice location:
  • Phone: 937-378-6118
  • Fax:
Mailing address:
  • Phone: 937-217-3130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberCOND.20263558-SP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: