Provider Demographics
NPI:1013082288
Name:FULLER, SUSAN A (DNP, NP)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:FULLER
Suffix:
Gender:F
Credentials:DNP, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2005
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27204-2005
Mailing Address - Country:US
Mailing Address - Phone:336-625-1172
Mailing Address - Fax:336-625-6434
Practice Address - Street 1:300 MACK RD
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27205-1066
Practice Address - Country:US
Practice Address - Phone:336-625-1172
Practice Address - Fax:336-625-6434
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200909363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003515Medicaid
NC2594298Medicare PIN