Provider Demographics
NPI:1790266179
Name:FULKERSON, HENLEY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HENLEY
Middle Name:
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 1:1173 ROCK SPRINGS RD STE 105
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-8414
Mailing Address - Country:US
Mailing Address - Phone:270-314-6708
Mailing Address - Fax:
Practice Address - Street 1:1173 ROCK SPRINGS RD STE 105
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-8414
Practice Address - Country:US
Practice Address - Phone:270-314-6708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
TN14149923235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty