Provider Demographics
NPI:1114243458
Name:FENELON, TANISE (DPT)
Entity Type:Individual
Prefix:
First Name:TANISE
Middle Name:
Last Name:FENELON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 N LAKE HOWARD DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-3162
Mailing Address - Country:US
Mailing Address - Phone:863-293-4456
Mailing Address - Fax:
Practice Address - Street 1:650 N LAKE HOWARD DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-3162
Practice Address - Country:US
Practice Address - Phone:863-293-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23791225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist