Provider Demographics
NPI:1215325881
Name:FULKS, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FULKS
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5210 HIGHLAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1970
Practice Address - Country:US
Practice Address - Phone:248-674-9560
Practice Address - Fax:248-674-9562
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016644225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist