Provider Demographics
NPI:1255625711
Name:FULLERTON, AMANDA (MOT, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 COUNTRY DOWNS DR
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-4310
Mailing Address - Country:US
Mailing Address - Phone:314-541-7938
Mailing Address - Fax:
Practice Address - Street 1:2120 BRYAN VALLEY COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3495
Practice Address - Country:US
Practice Address - Phone:314-774-1859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010025352225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist