Provider Demographics
NPI:1225174048
Name:FENNEMAN, MOLLY ANN (MSN)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANN
Last Name:FENNEMAN
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3028
Mailing Address - Country:US
Mailing Address - Phone:317-252-4831
Mailing Address - Fax:317-252-4831
Practice Address - Street 1:200 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46225-1055
Practice Address - Country:US
Practice Address - Phone:317-637-4343
Practice Address - Fax:317-637-4189
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000271A163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care