Provider Demographics
NPI:1366910101
Name:FULLER, AMANDA JOY (OTRL)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:JOY
Last Name:FULLER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 STANTON ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-4677
Mailing Address - Country:US
Mailing Address - Phone:616-648-0301
Mailing Address - Fax:
Practice Address - Street 1:685 CITADEL DR E STE 250
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5396
Practice Address - Country:US
Practice Address - Phone:719-685-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0005616225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics