Provider Demographics
NPI:1205661097
Name:FULLERTON, SYDNEY
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:
Last Name:FULLERTON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:SYDNEY
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:726-202-3039
Mailing Address - Fax:
Practice Address - Street 1:201 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:OK
Practice Address - Zip Code:73030-1749
Practice Address - Country:US
Practice Address - Phone:580-369-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6614225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist