MEDICARE: MS. NANCY ANN 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	235Z00000X	Speech-Language Pathologist	SP. 6915	OH

General Provider Information

NPI Number	:	1962808964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NANCY ANN FULLER

Provider Business Mailing Address
First Line	:	3574 HEATHERWOOD AVE
Second Line	:
City	:	SPRINGFIELD
State	:	OH
Zip	:	45503-5307
Country	:	US
Telephone Number	:	937-546-5032
Fax Number	:

Provider Business Practice Location Address
First Line	:	1414 BOWMAN RD
Second Line	:
City	:	SPRINGFIELD
State	:	OH
Zip	:	45502-8826
Country	:	US
Telephone Number	:	937-546-5032
Fax Number	:

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

Provider Enumeration Date	:	11/18/2014
Last Update Date	:	11/18/2014

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