Provider Demographics
NPI:1164196366
Name:FULLMER, MELISSA LEE (LMT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LEE
Last Name:FULLMER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10724 FENCIK LN SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-3694
Mailing Address - Country:US
Mailing Address - Phone:505-238-6881
Mailing Address - Fax:
Practice Address - Street 1:10724 FENCIK LN SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-3694
Practice Address - Country:US
Practice Address - Phone:505-238-6881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7838225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist