Provider Demographics
NPI:1164686036
Name:FULLMER, SUE ANN (MA)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:ANN
Last Name:FULLMER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 CRESTLYN RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-4108
Mailing Address - Country:US
Mailing Address - Phone:717-846-3310
Mailing Address - Fax:
Practice Address - Street 1:65 BILLERBECK ST
Practice Address - Street 2:
Practice Address - City:NEW OXFORD
Practice Address - State:PA
Practice Address - Zip Code:17350-9375
Practice Address - Country:US
Practice Address - Phone:717-718-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL002053L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019320080003Medicaid