Healthcare Provider Details

I. General information

NPI: 1356963250
Provider Name (Legal Business Name): CRANDALL CASSIE FUERTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 RAYMOND DR STE 205
NAPERVILLE IL
60563-9791
US

IV. Provider business mailing address

17606 66TH CT
TINLEY PARK IL
60477-4022
US

V. Phone/Fax

Practice location:
  • Phone: 630-717-2300
  • Fax:
Mailing address:
  • Phone: 312-478-3584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036166408
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: