MEDICARE: SUZANNA FULLER NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP140492	TX

General Provider Information

NPI Number	:	1326504382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNA FULLER NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	223 KING ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-4421
Country	:	US
Telephone Number	:	936-622-0552
Fax Number	:	936-622-0554

Provider Business Practice Location Address
First Line	:	223 KING ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-4421
Country	:	US
Telephone Number	:	936-622-0552
Fax Number	:	936-622-0554

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2019
Last Update Date	:	01/12/2026

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