Provider Demographics
NPI:1447840657
Name:FULKERSON, SARA
Entity type:Individual
Prefix:
First Name:SARA
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 1:395 PALM COAST PKWY SW UNIT 4
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-4768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:395 PALM COAST PKWY SW UNIT 4
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4768
Practice Address - Country:US
Practice Address - Phone:904-512-0018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW17999104100000X
FLSW238861041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program