Basic Information
| Provider Information | |||||||||
| NPI: | 1811908221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5005 | ||||||||
| Address2: | 10000 BAY PINES BLVD 126 | ||||||||
| City: | BAY PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273986661 | ||||||||
| FaxNumber: | 7273989442 | ||||||||
| Practice Location | |||||||||
| Address1: | 10000 BAY PINES BLVD | ||||||||
| Address2: | |||||||||
| City: | BAY PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273986661 | ||||||||
| FaxNumber: | 7273989442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 11/26/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/17/2007 | ||||||||
| NPIReactivationDate: | 11/26/2008 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AY125 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.