Provider Demographics
NPI:1992964076
Name:FULLER, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 ASH SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-8939
Mailing Address - Country:US
Mailing Address - Phone:207-303-8283
Mailing Address - Fax:
Practice Address - Street 1:43 BAXTER BLVD
Practice Address - Street 2:MAINE MEDICAL PARTNERS OTOLARYNGOLOGY
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-797-5753
Practice Address - Fax:207-797-9571
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP2382231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist