Provider Demographics
NPI:1629581160
Name:FULKERSON, BRACI LEANNELL (MS-CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BRACI
Middle Name:LEANNELL
Last Name:FULKERSON
Suffix:
Gender:F
Credentials:MS-CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:NORRIS CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62869-1634
Mailing Address - Country:US
Mailing Address - Phone:618-841-9044
Mailing Address - Fax:
Practice Address - Street 1:800 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:NORRIS CITY
Practice Address - State:IL
Practice Address - Zip Code:62869-1634
Practice Address - Country:US
Practice Address - Phone:618-378-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146010823235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist