Healthcare Provider Details

I. General information

NPI: 1093246951
Provider Name (Legal Business Name): MRS. HEIDI MICHELLE FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS HEIDI MICHELLE WEESE

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 W WASHINGTON ST STE 1500
CHICAGO IL
60606-3485
US

IV. Provider business mailing address

PO BOX 772294
DETROIT MI
48277-2294
US

V. Phone/Fax

Practice location:
  • Phone: 847-502-4898
  • Fax: 847-504-5015
Mailing address:
  • Phone: 847-504-5000
  • Fax: 508-273-1241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number105141
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: