Provider Demographics
NPI:1679859631
Name:FULLER, IVONNE DE CARLO (MS)
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:DE CARLO
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:IVONNE
Other - Middle Name:DE CARLO
Other - Last Name:MOLINA ALVANEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14008 ROCKENBACH ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-2463
Mailing Address - Country:US
Mailing Address - Phone:818-601-7644
Mailing Address - Fax:
Practice Address - Street 1:1011 BALDWIN PARK BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-5806
Practice Address - Country:US
Practice Address - Phone:626-851-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20326235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist