Provider Demographics
NPI:1609457035
Name:FULLERTON, BROOKE HOPE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:HOPE
Last Name:FULLERTON
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 1:450 ISLAND RD APT 83
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07446-1144
Mailing Address - Country:US
Mailing Address - Phone:817-734-3425
Mailing Address - Fax:
Practice Address - Street 1:450 ISLAND RD APT 83
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-1144
Practice Address - Country:US
Practice Address - Phone:817-734-3425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-17
Last Update Date:2021-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant