Provider Demographics
NPI:1245443274
Name:FULSON, BRANDY DAWN (PTA)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:DAWN
Last Name:FULSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8331 S TOLEDO AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-1844
Mailing Address - Country:US
Mailing Address - Phone:918-857-0428
Mailing Address - Fax:
Practice Address - Street 1:6525 N MERIDIAN AVE STE 311
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1410
Practice Address - Country:US
Practice Address - Phone:405-721-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPTA698225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant