Basic Information
| Provider Information | |||||||||
| NPI: | 1053796003 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | CASSANDRA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARCIA | ||||||||
| OtherFirstName: | CASSANDRA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 729 | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830140729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076997667 | ||||||||
| FaxNumber: | 3072006597 | ||||||||
| Practice Location | |||||||||
| Address1: | 5237 HHR RANCH RD | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830149220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076997667 | ||||||||
| FaxNumber: | 3072006597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2015 | ||||||||
| LastUpdateDate: | 07/20/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT1570 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT1570 | 01 | WY | WYOMING LICENSE | OTHER |