Provider Demographics
NPI:1215344023
Name:FULLER ZURENDA, MARIE ADELFA (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:ADELFA
Last Name:FULLER ZURENDA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 LYN DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-3661
Mailing Address - Country:US
Mailing Address - Phone:406-521-0052
Mailing Address - Fax:
Practice Address - Street 1:1009 FLAMELEAF CT
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-8611
Practice Address - Country:US
Practice Address - Phone:786-217-7544
Practice Address - Fax:336-776-0099
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9318224Z00000X
FLOTA13777224Z00000X
ID2002224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7118Medicaid