Provider Demographics
NPI:1578137923
Name:FASULLO, BRIANNA (DPT)
Entity Type:Individual
Prefix:MS
First Name:BRIANNA
Middle Name:
Last Name:FASULLO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 HATCHELL LN
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-3015
Mailing Address - Country:US
Mailing Address - Phone:225-380-1894
Mailing Address - Fax:225-380-1896
Practice Address - Street 1:601 HATCHELL LN
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-3015
Practice Address - Country:US
Practice Address - Phone:225-380-1894
Practice Address - Fax:225-380-1896
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist