Provider Demographics
NPI:1780362665
Name:FULLER, RACHEL (COTA/L)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10816 CREEK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-8218
Mailing Address - Country:US
Mailing Address - Phone:270-498-0841
Mailing Address - Fax:
Practice Address - Street 1:50 JOACHIM DR
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4474
Practice Address - Country:US
Practice Address - Phone:850-898-9506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19105224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant