Provider Demographics
NPI:1275738239
Name:FENN, RUBY DORONE (PT)
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:DORONE
Last Name:FENN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:RUBY
Other - Middle Name:C
Other - Last Name:DORONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 LAKE DAVENPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-9405
Mailing Address - Country:US
Mailing Address - Phone:863-256-5030
Mailing Address - Fax:869-256-5030
Practice Address - Street 1:109 LAKE DAVENPORT BLVD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-9405
Practice Address - Country:US
Practice Address - Phone:863-256-5030
Practice Address - Fax:863-256-5531
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19949225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist