Provider Demographics
NPI:1053796003
Name:FULLER, CASSANDRA ANN (DPT)
Entity type:Individual
Prefix:MS
First Name:CASSANDRA
Middle Name:ANN
Last Name:FULLER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:CASSANDRA
Other - Middle Name:ANN
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7811
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-7811
Mailing Address - Country:US
Mailing Address - Phone:307-699-7667
Mailing Address - Fax:307-200-6403
Practice Address - Street 1:5310 SOUTH PARK DRIVE
Practice Address - Street 2:SUITE 4
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002
Practice Address - Country:US
Practice Address - Phone:307-262-6372
Practice Address - Fax:307-200-6403
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT1570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYPT1570OtherWYOMING LICENSE