Provider Demographics
NPI:1770151797
Name:FULKERSON, KERI ANN
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:ANN
Last Name:FULKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 GREENTREE LN NE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9793
Mailing Address - Country:US
Mailing Address - Phone:616-889-9532
Mailing Address - Fax:
Practice Address - Street 1:2730 5 MILE RD NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6518
Practice Address - Country:US
Practice Address - Phone:616-426-9159
Practice Address - Fax:616-222-0294
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010898871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical