Healthcare Provider Details

I. General information

NPI: 1144500018
Provider Name (Legal Business Name): JUSTIN SCOTT FULKERSON ACNP-BC, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6766 W SUNRISE BLVD STE 100
PLANTATION FL
33313-6072
US

IV. Provider business mailing address

1997 NE 15TH AVE
WILTON MANORS FL
33305-3262
US

V. Phone/Fax

Practice location:
  • Phone: 954-583-8472
  • Fax:
Mailing address:
  • Phone: 803-730-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-009025
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209009025
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number18087
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11018636
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: