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General NPI Number Information
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NPI Number | 1295303196
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Entity Type | Individual
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Provider Name | ANDREW MACKENZIE FULLER CF-SLP
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Gender | Male
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Dates
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Enumeration Date | 06/16/2021
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Last Update Date | 06/16/2021
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Provider Practice Location Address
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Address Line | 10401 W CHARLESTON BLVD
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City | LAS VEGAS
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State | NV
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Zip | 89135-1151
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Country | US
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Telephone | 702-207-4242
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Fax |
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Provider Business Mailing Address
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Address Line | 935 KESWICK BLVD
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City | LOUISVILLE
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State | KY
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Zip | 40217-2136
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Country | US
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Telephone | 502-341-9369
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SP-3013
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License Number State | NV
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