Provider Demographics
NPI:1184684920
Name:FENNIMORE, GAIL HERNDON (PT)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:HERNDON
Last Name:FENNIMORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4012 PARK RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2377
Mailing Address - Country:US
Mailing Address - Phone:704-332-4834
Mailing Address - Fax:704-372-9653
Practice Address - Street 1:4012 PARK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2377
Practice Address - Country:US
Practice Address - Phone:704-332-4834
Practice Address - Fax:704-372-9653
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC56-1480824OtherFEDERAL TAX ID
NC7211539Medicaid
NC64-42619OtherUNITED HEALTHCARE
NC0103COtherBLUE CROSS BLUE SHIELD