Provider Demographics
NPI:1821560467
Name:FULLINGTON, RYAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:FULLINGTON
Suffix:
Gender:M
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 1:950 WESTON HILLS DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3758
Mailing Address - Country:US
Mailing Address - Phone:262-364-9221
Mailing Address - Fax:
Practice Address - Street 1:950 WESTON HILLS DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-3758
Practice Address - Country:US
Practice Address - Phone:262-364-9221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14512-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist