Provider Demographics
NPI:1184907990
Name:FULLER, ASHLEY M (SPEECH PATHOLIGIST)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:M
Last Name:FULLER
Suffix:
Gender:F
Credentials:SPEECH PATHOLIGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:NY
Mailing Address - Zip Code:14892-1445
Mailing Address - Country:US
Mailing Address - Phone:607-948-4047
Mailing Address - Fax:607-565-2200
Practice Address - Street 1:456 BROAD ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:NY
Practice Address - Zip Code:14892-1445
Practice Address - Country:US
Practice Address - Phone:607-948-4047
Practice Address - Fax:607-565-2200
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021178-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist