Provider Demographics
NPI:1053714337
Name:FULLER, CORY RYAN (DPT)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:RYAN
Last Name:FULLER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 2ND AVE E
Mailing Address - Street 2:SUITE C
Mailing Address - City:ONEONTA
Mailing Address - State:AL
Mailing Address - Zip Code:35121-1412
Mailing Address - Country:US
Mailing Address - Phone:205-274-0922
Mailing Address - Fax:205-274-0924
Practice Address - Street 1:410 2ND AVE E
Practice Address - Street 2:SUITE C
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-1412
Practice Address - Country:US
Practice Address - Phone:205-274-0922
Practice Address - Fax:205-274-0924
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH7080225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist