Provider Demographics
NPI:1679290522
Name:FULLMER, SU-YONG
Entity Type:Individual
Prefix:MRS
First Name:SU-YONG
Middle Name:
Last Name:FULLMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 66TH AVE E
Mailing Address - Street 2:
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-1445
Mailing Address - Country:US
Mailing Address - Phone:253-831-4910
Mailing Address - Fax:
Practice Address - Street 1:200 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-5015
Practice Address - Country:US
Practice Address - Phone:800-440-3305
Practice Address - Fax:866-369-4424
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2023-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61178626363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty