Provider Demographics
NPI:1144500018
Name:FULKERSON, JUSTIN SCOTT (ACNP-BC, CRNA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SCOTT
Last Name:FULKERSON
Suffix:
Gender:M
Credentials:ACNP-BC, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1997 NE 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-3262
Mailing Address - Country:US
Mailing Address - Phone:803-730-2778
Mailing Address - Fax:
Practice Address - Street 1:6766 W SUNRISE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33313-6072
Practice Address - Country:US
Practice Address - Phone:954-583-8472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18087363LA2100X
IL209-009025367500000X
FL11018636367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care