MEDICARE: SHANNON FULLER RPT

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	225100000X	Physical Therapist	PTH7164	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7542411	OTHER	AL	DRIVER'S LICENSE
2	PTH7164	OTHER	AL	AL BOARD OF PHYSICAL THERAPY

General Provider Information

NPI Number	:	1275947814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON FULLER RPT

Provider Business Mailing Address
First Line	:	1514 OWENS ST
Second Line	:
City	:	GADSDEN
State	:	AL
Zip	:	35904-4938
Country	:	US
Telephone Number	:	256-543-1030
Fax Number	:	256-439-2830

Provider Business Practice Location Address
First Line	:	1235 YANCEY ST
Second Line	:
City	:	ROANOKE
State	:	AL
Zip	:	36274-2141
Country	:	US
Telephone Number	:	334-863-3535
Fax Number	:	334-863-7276

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

Provider Enumeration Date	:	06/11/2014
Last Update Date	:	06/11/2014

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