Provider Demographics
NPI:1811908221
Name:FULTON, SUSAN ELIZABETH (MS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:FULTON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 THEMIS ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5223
Mailing Address - Country:US
Mailing Address - Phone:573-290-2493
Mailing Address - Fax:
Practice Address - Street 1:1727 THEMIS ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5223
Practice Address - Country:US
Practice Address - Phone:573-290-2493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2023-09-20
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-11-26
Provider Licenses
StateLicense IDTaxonomies
MO2017034344231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist