Healthcare Provider Details

I. General information

NPI: 1659803070
Provider Name (Legal Business Name): LAUREN E FULKS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 VERSAILLES RD
LEXINGTON KY
40504-1405
US

IV. Provider business mailing address

3333 BURNET AVE
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-3573
  • Fax: 859-323-0096
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberTP456
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number58181
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number58181
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: