Basic Information
| Provider Information | |||||||||
| NPI: | 1942629332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULTS | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
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| Credential: | P.T. | ||||||||
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| OtherLastName: | SANDERS | ||||||||
| OtherFirstName: | HEATHER | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 OAKMONT LN STE 600C | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305756250 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10302 PROSPERITY CIR STE 101 | ||||||||
| Address2: | |||||||||
| City: | CAMBY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461139002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175484172 | ||||||||
| FaxNumber: | 3175488308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 10/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05011172A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.