Provider Demographics
NPI:1346306198
Name:FENWICK, KELLY MARIE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:FENWICK
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:KENNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:2817 REILLY ROAD
Mailing Address - Street 2:WOMACK ARMY MEDICAL CENTER MCXC COD CREDENTIALS
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:2817 REILLY ROAD
Practice Address - Street 2:WAMC STOP A MCXC DPC ED CREDENTIALS DEPARTMENT OF THE A
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-7301
Practice Address - Country:US
Practice Address - Phone:910-907-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4921225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist