Provider Demographics
NPI:1003230475
Name:FULLEN, LAUREN ASHLEY (MS CCC-SLP, MBA)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:ASHLEY
Last Name:FULLEN
Suffix:
Gender:F
Credentials:MS CCC-SLP, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-3201
Mailing Address - Country:US
Mailing Address - Phone:276-642-7900
Mailing Address - Fax:276-642-8091
Practice Address - Street 1:103 NORTH ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-3201
Practice Address - Country:US
Practice Address - Phone:276-642-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4084235Z00000X
VA2202006003235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist