Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | 307722 | LA |
NPI | 1326606716 |
---|---|
Provider Name | Tiffany Fuller |
First Address | Monroe, LA 71203-9008 |
Second Address | Monroe, LA 71203-9008 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2019 |
Last Update Date | 31/05/2019 |