Provider Demographics
NPI:1366741720
Name:FULLERTON, BRENNA SULLIVAN (MD)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:SULLIVAN
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BRENNA
Other - Middle Name:ELIZABETH
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1720 S ORANGE AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2967
Mailing Address - Country:US
Mailing Address - Phone:140-754-0100
Mailing Address - Fax:407-540-1011
Practice Address - Street 1:1720 S ORANGE AVE STE 500
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2967
Practice Address - Country:US
Practice Address - Phone:140-754-0100
Practice Address - Fax:407-540-1011
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA259770208600000X
390200000X
FLME1501992086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program