MEDICARE: LAURA LYN FULLER SLP

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	235Z00000X	Speech-Language Pathologist	SLP8363	AZ

General Provider Information

NPI Number	:	1255773933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA LYN FULLER SLP

Provider Business Mailing Address
First Line	:	3012 N 17TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-6112
Country	:	US
Telephone Number	:	480-824-8889
Fax Number	:

Provider Business Practice Location Address
First Line	:	3012 N 17TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-6112
Country	:	US
Telephone Number	:	480-824-8889
Fax Number	:

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

Provider Enumeration Date	:	07/23/2013
Last Update Date	:	08/13/2019

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Directions to “ LAURA LYN FULLER SLP” Practice Location

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