Provider Demographics
NPI:1134820160
Name:FULTON, BRENNAH MAE (OTR/L)
Entity type:Individual
Prefix:
First Name:BRENNAH
Middle Name:MAE
Last Name:FULTON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3116 EMERSON AVE S APT 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2774
Mailing Address - Country:US
Mailing Address - Phone:715-581-6268
Mailing Address - Fax:
Practice Address - Street 1:9220 BASS LAKE RD STE 260
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3019
Practice Address - Country:US
Practice Address - Phone:763-533-0363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107120225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist