Individual
MRS. HAILEY RENE FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
1250 WALLACE BLVD, AMARILLO, TX 79106-1741
(806) 353-3596
Mailing address
1716 S LA SALLE ST, AMARILLO, TX 79106-5913
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
2067687
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2067687
STATE LICENSE
TX
Enumeration date
07/21/2011
Last updated
07/21/2011
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