Healthcare Provider Details

I. General information

NPI: 1043870314
Provider Name (Legal Business Name): HEATHER NICOLE FULHORST FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER NICOLE FULHORST FNP-BC

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W CARPENTER ST
SPRINGFIELD IL
62702-4902
US

IV. Provider business mailing address

PO BOX 19248
SPRINGFIELD IL
62794-9248
US

V. Phone/Fax

Practice location:
  • Phone: 217-546-5395
  • Fax:
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019724
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041361813
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: