Provider Demographics
NPI:1598230948
Name:FULLENKAMP, BRIANNA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:BRIANNA
Middle Name:
Last Name:FULLENKAMP
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5716 W OVERLAND PASS
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61607-1110
Mailing Address - Country:US
Mailing Address - Phone:309-678-5610
Mailing Address - Fax:
Practice Address - Street 1:6809 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2812
Practice Address - Country:US
Practice Address - Phone:309-981-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist