Provider Demographics
NPI:1295854115
Name:FULLAR, SUZANNE A (RN, MSN, PNP)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:A
Last Name:FULLAR
Suffix:
Gender:F
Credentials:RN, MSN, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 S. HAYWOOD ST.
Mailing Address - Street 2:JACKSON COUNTY PSYCHOLOGICAL SERVICES
Mailing Address - City:WAYNESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28786
Mailing Address - Country:US
Mailing Address - Phone:828-456-2997
Mailing Address - Fax:828-456-2996
Practice Address - Street 1:669 S. HAYWOOD ST.
Practice Address - Street 2:JACKSON COUNTY PSYCHOLOGICAL SERVICES
Practice Address - City:WAYNESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28786
Practice Address - Country:US
Practice Address - Phone:828-456-2997
Practice Address - Fax:828-456-2996
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC300031363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004794Medicaid