Healthcare Provider Details

I. General information

NPI: 1558077974
Provider Name (Legal Business Name): SARA DAKOTA FULGHUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13203 GLOBE DR STE 111
MOUNT PLEASANT WI
53177-1616
US

IV. Provider business mailing address

6058 109TH AVE
KENOSHA WI
53142-7598
US

V. Phone/Fax

Practice location:
  • Phone: 262-287-0090
  • Fax:
Mailing address:
  • Phone: 847-702-7363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number8155-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: