Provider Demographics
NPI:1780083014
Name:FULKERSON, SALOME
Entity type:Individual
Prefix:MS
First Name:SALOME
Middle Name:
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 1:1476 HIGHWAY 85 W
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:KY
Mailing Address - Zip Code:42372-9534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1476 HWY 85 WEST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:KY
Practice Address - Zip Code:42372
Practice Address - Country:US
Practice Address - Phone:270-499-2915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8123251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health