Provider Demographics
NPI:1922420736
Name:WAYLAND FULLER, TINA RENEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:RENEE
Last Name:WAYLAND FULLER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:RENEE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:6397 S MISTYGLEN AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6788
Mailing Address - Country:US
Mailing Address - Phone:208-914-3167
Mailing Address - Fax:
Practice Address - Street 1:895 N 6TH E
Practice Address - Street 2:
Practice Address - City:MT HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2207
Practice Address - Country:US
Practice Address - Phone:208-580-9806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1095224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant