Provider Demographics
NPI:1093246951
Name:FULLER, HEIDI MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:MICHELLE
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:HEIDI
Other - Middle Name:MICHELLE
Other - Last Name:WEESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 772294
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2294
Mailing Address - Country:US
Mailing Address - Phone:847-504-5000
Mailing Address - Fax:508-273-1241
Practice Address - Street 1:168 N CLINTON ST FL 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-1419
Practice Address - Country:US
Practice Address - Phone:847-502-4898
Practice Address - Fax:847-504-5015
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA105141213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program