Provider Demographics
NPI:1518849207
Name:FULLMER, NICOLE AUTUMN (HAD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:AUTUMN
Last Name:FULLMER
Suffix:
Gender:F
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 MONO WAY
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5233
Mailing Address - Country:US
Mailing Address - Phone:209-532-9337
Mailing Address - Fax:
Practice Address - Street 1:722 MONO WAY
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5233
Practice Address - Country:US
Practice Address - Phone:209-532-9337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-23
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA9131237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist