=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972762219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEIDI LYNN FULLERTON MSPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2008
-----------------------------------------------------
Last Update Date | 07/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 899 CECIL AVE S
-----------------------------------------------------
City | MILLERSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21108-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-987-1644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 WOODMAN ST
-----------------------------------------------------
City | GLOUCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01930-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-699-2016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 22562
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------