Provider Demographics
NPI:1376768564
Name:FULLER, ADRIENNE (MS,CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:ADRIENNE
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 SUNSET PALM DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-8188
Mailing Address - Country:US
Mailing Address - Phone:407-970-8484
Mailing Address - Fax:
Practice Address - Street 1:1907 SUNSET PALM DR
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-8188
Practice Address - Country:US
Practice Address - Phone:407-970-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 7338235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891325100Medicaid