Provider Demographics
NPI:1295722155
Name:FULLERTON, SUSAN (MSN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4923 OGLETOWN STANTON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2081
Mailing Address - Country:US
Mailing Address - Phone:302-225-0451
Mailing Address - Fax:302-225-0472
Practice Address - Street 1:4923 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2081
Practice Address - Country:US
Practice Address - Phone:302-225-0451
Practice Address - Fax:302-225-0472
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC000097363L00000X
DELG0000136363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404275100Medicaid
DE1000024659Medicaid
NJ0046973Medicaid
MD036MC647Medicare PIN
DE00769N74Medicare PIN
MD404275100Medicaid