Provider Demographics
NPI:1528284486
Name:FULLER-ALWES, SHAWNDA (AUDIOLOGIST)
Entity type:Individual
Prefix:MS
First Name:SHAWNDA
Middle Name:
Last Name:FULLER-ALWES
Suffix:
Gender:F
Credentials:AUDIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-326-8630
Mailing Address - Fax:217-344-8047
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-4375
Practice Address - Fax:217-326-2336
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000955231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4117OtherHAMP PROVIDER ID
7216OtherPERSONALCARE PROV ID
IL203OtherBLUE CROSS PROV ID
113326OtherHEALTHLINK PROV ID
140091Medicare ID - Type Unspecified