Healthcare Provider Details

I. General information

NPI: 1366741720
Provider Name (Legal Business Name): BRENNA SULLIVAN FULLERTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRENNA ELIZABETH SULLIVAN MD

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 S ORANGE AVE STE 500
ORLANDO FL
32806-2967
US

IV. Provider business mailing address

1720 S ORANGE AVE STE 500
ORLANDO FL
32806-2967
US

V. Phone/Fax

Practice location:
  • Phone: 140-754-0100
  • Fax: 407-540-1011
Mailing address:
  • Phone: 140-754-0100
  • Fax: 407-540-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number259770
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberME150199
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: