Provider Demographics
NPI:1689102212
Name:FUSSELMAN, HEATHER DAWN
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:DAWN
Last Name:FUSSELMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 MONUMENT RD
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-3523
Mailing Address - Country:US
Mailing Address - Phone:580-716-1976
Mailing Address - Fax:
Practice Address - Street 1:1608 MONUMENT RD
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-3523
Practice Address - Country:US
Practice Address - Phone:580-716-1976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator