Provider Demographics
NPI:1750019469
Name:FULLER, SARAH STOLWORTHY (ATC)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:STOLWORTHY
Last Name:FULLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1688 S 800 E
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-8033
Mailing Address - Country:US
Mailing Address - Phone:502-424-6290
Mailing Address - Fax:
Practice Address - Street 1:150 E 1230 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2676
Practice Address - Country:US
Practice Address - Phone:801-422-2946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12900248-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer