Provider Demographics
NPI:1558077974
Name:FULGHUM, SARA DAKOTA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:DAKOTA
Last Name:FULGHUM
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 1:6058 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7598
Mailing Address - Country:US
Mailing Address - Phone:847-702-7363
Mailing Address - Fax:
Practice Address - Street 1:13203 GLOBE DR STE 111
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1616
Practice Address - Country:US
Practice Address - Phone:262-287-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8155-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist