Provider Demographics
NPI:1558611699
Name:FULLER, MELISSA S (CGC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:S
Last Name:FULLER
Suffix:
Gender:F
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 BOB PETERS GRV STE 309
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-4533
Mailing Address - Country:US
Mailing Address - Phone:719-365-9867
Mailing Address - Fax:719-365-9520
Practice Address - Street 1:525 BOB PETERS GRV STE 309
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909
Practice Address - Country:US
Practice Address - Phone:719-365-9867
Practice Address - Fax:719-365-9520
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MONO LICENSE170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS