Provider Demographics
NPI:1467963785
Name:FULLER, PENELOPE NOELL (COTA)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:NOELL
Last Name:FULLER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4308 ABBEY PL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5601
Mailing Address - Country:US
Mailing Address - Phone:919-971-3194
Mailing Address - Fax:
Practice Address - Street 1:3420 HOLLOWAY ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-3522
Practice Address - Country:US
Practice Address - Phone:919-596-9464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11161224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant