Healthcare Provider Details

I. General information

NPI: 1760318083
Provider Name (Legal Business Name): ALEX FULLENKAMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19300 DETROIT RD STE 201
ROCKY RIVER OH
44116-1846
US

IV. Provider business mailing address

19300 DETROIT RD STE 201
ROCKY RIVER OH
44116-1846
US

V. Phone/Fax

Practice location:
  • Phone: 216-408-7555
  • Fax:
Mailing address:
  • Phone: 216-408-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0042510
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: