Provider Demographics
NPI:1699035907
Name:FULLER, SARA MICHELE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:MICHELE
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 1:6230 HATHAWAY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-9545
Mailing Address - Country:US
Mailing Address - Phone:260-615-4437
Mailing Address - Fax:
Practice Address - Street 1:515 N MAIN ST
Practice Address - Street 2:
Practice Address - City:AVILLA
Practice Address - State:IN
Practice Address - Zip Code:46710-9601
Practice Address - Country:US
Practice Address - Phone:260-897-2841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002824A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist