Provider Demographics
NPI:1083184634
Name:FULLER, ASHLEY GRACE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:GRACE
Last Name:FULLER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 PLAZA DRIVE SUITE C
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765
Mailing Address - Country:US
Mailing Address - Phone:407-694-3603
Mailing Address - Fax:
Practice Address - Street 1:251 PLAZA DRIVE SUITE C
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765
Practice Address - Country:US
Practice Address - Phone:407-694-3603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4265235Z00000X
FLSA16690235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist