Provider Demographics
NPI:1821135013
Name:FULLER, SUZANNE MARIE
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:MARIE
Last Name:FULLER
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 1:13130 HADLEY ST
Mailing Address - Street 2:#2011
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-2781
Mailing Address - Country:US
Mailing Address - Phone:913-402-7624
Mailing Address - Fax:
Practice Address - Street 1:13130 HADLEY ST
Practice Address - Street 2:#2011
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-2781
Practice Address - Country:US
Practice Address - Phone:913-402-7624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor