Individual
MRS. PATRICIA FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OTR
Contact information
Practice address
504 LAKELAND RD, SHAWANO, WI 54166-3836
(715) 526-5547
Mailing address
615 S LINCOLN ST, SHAWANO, WI 54166-2915
(715) 524-5094
Taxonomy
Speciality
Code
Description
License number
State
225XP0200X
Pediatric Occupational Therapist
Primary
2196-026
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
40622700
—
WI
Enumeration date
04/18/2008
Last updated
04/18/2008
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