Healthcare Provider Details

I. General information

NPI: 1841434941
Provider Name (Legal Business Name): FULLER PRIMARY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 FRIEDENS CHURCH ROAD
MCLEANSVILLE NC
27301-0459
US

IV. Provider business mailing address

PO BOX 459
MC LEANSVILLE NC
27301-0459
US

V. Phone/Fax

Practice location:
  • Phone: 336-382-9494
  • Fax: 336-697-1580
Mailing address:
  • Phone: 336-697-1550
  • Fax: 336-697-1580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200909
License Number StateNC

VIII. Authorized Official

Name: SUSAN A FULLER
Title or Position: PRESIDENT
Credential: FNP
Phone: 336-382-9494