MEDICARE: DOREE FULLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	1035	CA

General Provider Information

NPI Number	:	1144171109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOREE FULLER

Provider Business Mailing Address
First Line	:	4790 PETRIFIED FOREST RD
Second Line	:
City	:	CALISTOGA
State	:	CA
Zip	:	94515-9579
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4790 PETRIFIED FOREST RD
Second Line	:
City	:	CALISTOGA
State	:	CA
Zip	:	94515-9579
Country	:	US
Telephone Number	:	707-291-4250
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2026
Last Update Date	:	02/05/2026

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Directions to “ DOREE FULLER ” Practice Location

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