Provider Demographics
NPI:1689848764
Name:FULLER, PATRICIA (OTR)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 S LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2915
Mailing Address - Country:US
Mailing Address - Phone:715-524-5094
Mailing Address - Fax:
Practice Address - Street 1:504 LAKELAND RD
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3836
Practice Address - Country:US
Practice Address - Phone:715-526-5547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2196-026225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40622700Medicaid