Provider Demographics
NPI:1295303196
Name:FULLER, ANDREW MACKENZIE (CF-SLP)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:MACKENZIE
Last Name:FULLER
Suffix:
Gender:M
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 KESWICK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-2136
Mailing Address - Country:US
Mailing Address - Phone:502-341-9369
Mailing Address - Fax:
Practice Address - Street 1:10401 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89135-1151
Practice Address - Country:US
Practice Address - Phone:702-207-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-3013235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist