Provider Demographics
NPI:1073101796
Name:FENTRESS, CHARLOTTE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:FENTRESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5709 9TH DR W
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-3074
Mailing Address - Country:US
Mailing Address - Phone:757-621-8114
Mailing Address - Fax:
Practice Address - Street 1:16708 BOTHELL EVERETT HWY STE 202
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-6345
Practice Address - Country:US
Practice Address - Phone:425-286-2712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist