Provider Demographics
NPI:1730713173
Name:FULLER, HEIDI
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:FULLER
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 1:12121 SHELBYVILLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1094
Mailing Address - Country:US
Mailing Address - Phone:502-341-1599
Mailing Address - Fax:
Practice Address - Street 1:12121 SHELBYVILLE RD STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1094
Practice Address - Country:US
Practice Address - Phone:502-341-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
965136OtherMEDICAL SERVICES
KY000965136OtherCRANIAL PROSTHESIS