Provider Demographics
NPI:1508581604
Name:FULLER, MELANIE NICOLE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:NICOLE
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 N SUPERSTITION LN APT C
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-6910
Mailing Address - Country:US
Mailing Address - Phone:928-701-3339
Mailing Address - Fax:
Practice Address - Street 1:2809 N SUPERSTITION LN APT C
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-6910
Practice Address - Country:US
Practice Address - Phone:928-701-3339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA141572355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant