MEDICARE: FULCRUM CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	72566	OK

General Provider Information

NPI Number	:	1124512322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULCRUM CLINIC LLC

Provider Business Mailing Address
First Line	:	1601 SW 89TH ST STE D100
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-6378
Country	:	US
Telephone Number	:	405-546-7888
Fax Number	:	844-518-2784

Provider Business Practice Location Address
First Line	:	1601 SW 89TH ST STE D100
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-6378
Country	:	US
Telephone Number	:	405-546-7888
Fax Number	:	844-518-2784

Authorized Official
Title or Position	:	OFFICE MANAGER AND CO-OWNER
Name	:	SONYA DIANE FERGESON
Credential	:
Telephone Number	:	405-546-7888

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	12/07/2021

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