Provider Demographics
NPI:1346973492
Name:FENOFF, CHARMAIN BAKER (LMT #014374)
Entity Type:Individual
Prefix:MRS
First Name:CHARMAIN
Middle Name:BAKER
Last Name:FENOFF
Suffix:
Gender:F
Credentials:LMT #014374
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 FOX RUN RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12932-2904
Mailing Address - Country:US
Mailing Address - Phone:518-524-6520
Mailing Address - Fax:
Practice Address - Street 1:112 FOX RUN RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NY
Practice Address - Zip Code:12932-2904
Practice Address - Country:US
Practice Address - Phone:518-524-6520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014374225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty