Healthcare Provider Details

I. General information

NPI: 1669090783
Provider Name (Legal Business Name): SUSAN RUTKOWSKI FULLER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 04/28/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 ROGERS RD
WAKE FOREST NC
27587-7634
US

IV. Provider business mailing address

3801 WAKE FOREST RD STE 210
RALEIGH NC
27609-6864
US

V. Phone/Fax

Practice location:
  • Phone: 919-787-7246
  • Fax: 919-787-7247
Mailing address:
  • Phone: 919-787-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5013256
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5013256
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: