TINA RENEE WAYLAND FULLER

MT HOME, ID
NPI1922420736
Former NameTINA RENEE SMITH
Entity TypeIndividual
GenderFemale
Sole Proprietor ?No
Primary Taxonomy224Z00000X Occupational Therapy Assistant
(Licence: ID  OTA-1095)
Enumeration Date2014-01-13
Last Update Date2014-01-13
Business Address
-- TINA RENEE WAYLAND FULLER COTA/L
895 N 6TH E
MT HOME, ID 83647-2207
Phone number: 208-580-9806
Mailing Address
-- TINA RENEE WAYLAND FULLER COTA/L
6397 S MISTYGLEN AVE
BOISE, ID 83709-6788
Phone number: 208-914-3167