Provider Demographics
NPI:1700096799
Name:FULKS, SHERRY RENAI (EARLY INTERVENTION)
Entity Type:Individual
Prefix:MRS
First Name:SHERRY
Middle Name:RENAI
Last Name:FULKS
Suffix:
Gender:F
Credentials:EARLY INTERVENTION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 BRISTOL LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-7948
Mailing Address - Country:US
Mailing Address - Phone:859-497-0704
Mailing Address - Fax:859-497-0704
Practice Address - Street 1:159 BRISTOL LN
Practice Address - Street 2:
Practice Address - City:MOUNT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-7948
Practice Address - Country:US
Practice Address - Phone:859-497-0704
Practice Address - Fax:859-497-0704
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1667251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1667OtherGATEWAY FIRST STEPS PROV.