Healthcare Provider Details

I. General information

NPI: 1881908325
Provider Name (Legal Business Name): HEIDI ANN FARRELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 W NORTH AVE SUITE 402
MELROSE PARK IL
60160-1634
US

IV. Provider business mailing address

21903 W KNOLLWOOD DR
PLAINFIELD IL
60544-7038
US

V. Phone/Fax

Practice location:
  • Phone: 708-486-2600
  • Fax:
Mailing address:
  • Phone: 708-486-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: