Provider Demographics
NPI:1376552612
Name:FENNIG, ROBERTA LEE (DO)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:LEE
Last Name:FENNIG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6955 N MESA ST
Mailing Address - Street 2:SUITE 113
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-4442
Mailing Address - Country:US
Mailing Address - Phone:915-545-1509
Mailing Address - Fax:915-544-5357
Practice Address - Street 1:6955 N MESA ST
Practice Address - Street 2:SUITE 113
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-4442
Practice Address - Country:US
Practice Address - Phone:915-545-1509
Practice Address - Fax:915-544-5357
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2873204D00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME0694Medicaid
NME0694Medicaid