Provider Demographics
NPI:1205186269
Name:FENTON, CHRISTINE NAOMI (DPT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:NAOMI
Last Name:FENTON
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 1:200 E ALESSANDRO BLVD UNIT 17
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 E ALESSANDRO BLVD.
Practice Address - Street 2:UNIT #17
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-6173
Practice Address - Country:US
Practice Address - Phone:951-202-7684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT39341172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker