Provider Demographics
NPI:1346040292
Name:FULLER, ALYSHA (PT, DPT)
Entity type:Individual
Prefix:
First Name:ALYSHA
Middle Name:
Last Name:FULLER
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ALYSHA
Other - Middle Name:
Other - Last Name:WONKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:401 CAMPBELL RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-4103
Mailing Address - Country:US
Mailing Address - Phone:252-767-3047
Mailing Address - Fax:
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1231
Practice Address - Country:US
Practice Address - Phone:919-350-8854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP18206225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist