Provider Demographics
NPI:1326424573
Name:FENNELL, EVELYN J
Entity Type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:J
Last Name:FENNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 6321
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74148
Mailing Address - Country:US
Mailing Address - Phone:918-378-4752
Mailing Address - Fax:
Practice Address - Street 1:1143 E 57TH PLACE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105
Practice Address - Country:US
Practice Address - Phone:918-378-4752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37V899650300376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide