| Doctor Name: | LISA JANE FULLENKAMP |
| NPI Number: | 1104082205 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MA, CCC-SLP |
| License Number: | 01568 |
| Business Practice Address: | 3000 Risen Son Blvd Council Bluffs, IA - 515031911 |
| Business Phone Number: | 7123660286 |
| Business Fax Number: | 7123660277 |
| Mailing Address: | 3000 Risen Son Blvd, COUNCIL BLUFFS |
| State: | IA |
| Postal Code: | 515031911 |
| Phone Number: | 7123660286 |
| Fax Number: | 7123660277 |
| NPI Enumeration Date: | 07/29/2008 |
| NPI Last Update Date: | 07/29/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | 01568 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IA |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |