Provider Demographics
NPI:1194833699
Name:FENN, ANDRAEA M (DC)
Entity Type:Individual
Prefix:DR
First Name:ANDRAEA
Middle Name:M
Last Name:FENN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 SCHOOSETT ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:MA
Mailing Address - Zip Code:02359-1822
Mailing Address - Country:US
Mailing Address - Phone:781-826-8804
Mailing Address - Fax:781-826-8805
Practice Address - Street 1:212 SCHOOSETT ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:MA
Practice Address - Zip Code:02359-1822
Practice Address - Country:US
Practice Address - Phone:781-826-8804
Practice Address - Fax:781-826-8805
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1520111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1610023Medicaid
MAY36126Medicare ID - Type Unspecified
MA1610023Medicaid