Provider Demographics
NPI:1275947814
Name:FULLER, SHANNON (RPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 OWENS ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35904-4938
Mailing Address - Country:US
Mailing Address - Phone:256-543-1030
Mailing Address - Fax:256-439-2830
Practice Address - Street 1:1235 YANCEY ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:AL
Practice Address - Zip Code:36274-2141
Practice Address - Country:US
Practice Address - Phone:334-863-3535
Practice Address - Fax:334-863-7276
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH7164225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7542411OtherDRIVER'S LICENSE
ALPTH7164OtherAL BOARD OF PHYSICAL THERAPY