Provider Demographics
NPI:1053308007
Name:FENNO, CHERYL M (OD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:M
Last Name:FENNO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S OAK ST
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2846
Mailing Address - Country:US
Mailing Address - Phone:509-684-5278
Mailing Address - Fax:
Practice Address - Street 1:102 S OAK ST
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2846
Practice Address - Country:US
Practice Address - Phone:509-684-5278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1733152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2005494Medicaid
WA2005494Medicaid
T44374Medicare UPIN