Provider Demographics
NPI:1679971717
Name:FULLAGAR, CHALLEY
Entity Type:Individual
Prefix:
First Name:CHALLEY
Middle Name:
Last Name:FULLAGAR
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 1:123 N EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-3313
Mailing Address - Country:US
Mailing Address - Phone:785-717-4130
Mailing Address - Fax:
Practice Address - Street 1:123 N EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-3313
Practice Address - Country:US
Practice Address - Phone:785-717-4130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3235235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist