Individual
TINA RENEE WAYLAND FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA/L
Contact information
Practice address
895 N 6TH E, MT HOME, ID 83647-2207
(208) 580-9806
Mailing address
6397 S MISTYGLEN AVE, BOISE, ID 83709-6788
(208) 914-3167
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
OTA-1095
ID
Other
Enumeration date
01/13/2014
Last updated
01/13/2014
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