Provider Demographics
NPI:1669090783
Name:FULLER, SUSAN RUTKOWSKI (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:RUTKOWSKI
Last Name:FULLER
Suffix:
Gender:
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 WAKE FOREST RD STE 210
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6864
Mailing Address - Country:US
Mailing Address - Phone:919-787-7246
Mailing Address - Fax:
Practice Address - Street 1:3635 ROGERS RD
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-7634
Practice Address - Country:US
Practice Address - Phone:919-787-7246
Practice Address - Fax:919-787-7247
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5013256363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily