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General NPI Number Information
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NPI Number | 1366910101
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Entity Type | Individual
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Provider Name | AMANDA JOY FULLER OTRL
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Gender | Female
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Dates
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Enumeration Date | 11/09/2018
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Last Update Date | 11/09/2018
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Provider Practice Location Address
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Address Line | 685 CITADEL DR E STE 250
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City | COLORADO SPRINGS
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State | CO
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Zip | 80909-5396
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Country | US
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Telephone | 719-685-7890
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Fax |
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Provider Business Mailing Address
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Address Line | 1129 STANTON ST
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City | COLORADO SPRINGS
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State | CO
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Zip | 80907-4677
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Country | US
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Telephone | 616-648-0301
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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 | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | OT.0005616
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License Number State | CO
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