Provider Demographics
NPI:1114075405
Name:FULLERTON, SUZANNE LANAY (OTRL)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:LANAY
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:LANAY
Other - Last Name:FULLERTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:12709 MEADOWS EDGE LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4443
Mailing Address - Country:US
Mailing Address - Phone:501-514-4938
Mailing Address - Fax:
Practice Address - Street 1:12709 MEADOWS EDGE LANE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-1802
Practice Address - Country:US
Practice Address - Phone:501-514-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1058225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR130689721Medicaid
AR5X798OtherBCBS