Provider Demographics
NPI:1225860570
Name:FULLMER, MACKENZIE (DPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:FULLMER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5480 FM 423 STE 2100
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75036-7914
Mailing Address - Country:US
Mailing Address - Phone:214-494-4643
Mailing Address - Fax:
Practice Address - Street 1:5480 FM 423 STE 2100
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75036-7914
Practice Address - Country:US
Practice Address - Phone:214-494-4643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1396782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist