Provider Demographics
NPI:1134950314
Name:FULLER, AMELIA E (LMT)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:E
Last Name:FULLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5364 W ROCKING CIRCLE ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-6312
Mailing Address - Country:US
Mailing Address - Phone:520-719-9671
Mailing Address - Fax:
Practice Address - Street 1:8700 E TANQUE VERDE RD STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85749-5701
Practice Address - Country:US
Practice Address - Phone:520-398-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18198225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist