Provider Demographics
NPI:1821281163
Name:FULKERSON, HALEY RENEE (RD)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:RENEE
Last Name:FULKERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-559-9407
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:912 WALLACE AVE STE 102
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-2405
Practice Address - Country:US
Practice Address - Phone:270-259-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY123904133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0944710Medicare PIN
KY0282420Medicare PIN
KY0282520Medicare PIN
KY0282320Medicare PIN
KY0282619Medicare PIN
KY0049228Medicare PIN
KY0282717Medicare PIN
KY0282817Medicare PIN