Provider Demographics
NPI:1972762219
Name:FULLERTON, HEIDI LYNN (MSPT)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LYNN
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WOODMAN ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-2021
Mailing Address - Country:US
Mailing Address - Phone:617-699-2016
Mailing Address - Fax:
Practice Address - Street 1:899 CECIL AVE S
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-2111
Practice Address - Country:US
Practice Address - Phone:410-987-1644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22562225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist