Provider Demographics
NPI:1023684073
Name:FULLER, TAYTUM FAY (MS, CCC SLP)
Entity type:Individual
Prefix:
First Name:TAYTUM
Middle Name:FAY
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS, CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2347 S SOUTHEAST BLVD APT 4
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-4535
Mailing Address - Country:US
Mailing Address - Phone:509-793-6564
Mailing Address - Fax:
Practice Address - Street 1:123 W CASCADE WAY
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6017
Practice Address - Country:US
Practice Address - Phone:509-624-3115
Practice Address - Fax:509-624-4374
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61160992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALL61304692OtherWASHINGTON STATE DEPARTMENT OF HEALTH