Provider Demographics
NPI:1356963250
Name:FUERTH, CRANDALL CASSIE
Entity type:Individual
Prefix:
First Name:CRANDALL
Middle Name:CASSIE
Last Name:FUERTH
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 1:17606 66TH CT
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-4022
Mailing Address - Country:US
Mailing Address - Phone:312-478-3584
Mailing Address - Fax:
Practice Address - Street 1:1000 N OAK AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-5703
Practice Address - Country:US
Practice Address - Phone:715-387-5267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty