Healthcare Provider Details

I. General information

NPI: 1689848764
Provider Name (Legal Business Name): PATRICIA FULLER OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 LAKELAND RD
SHAWANO WI
54166-3836
US

IV. Provider business mailing address

615 S LINCOLN ST
SHAWANO WI
54166-2915
US

V. Phone/Fax

Practice location:
  • Phone: 715-526-5547
  • Fax:
Mailing address:
  • Phone: 715-524-5094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2196-026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: