Provider Demographics
NPI:1376863423
Name:FENNELL, ERICA TERESA
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:TERESA
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 1:1436 BLAND SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:HARRELLS
Mailing Address - State:NC
Mailing Address - Zip Code:28444-7609
Mailing Address - Country:US
Mailing Address - Phone:910-532-4805
Mailing Address - Fax:910-532-4805
Practice Address - Street 1:1436 BLAND SCHOOL RD
Practice Address - Street 2:
Practice Address - City:HARRELLS
Practice Address - State:NC
Practice Address - Zip Code:28444-7609
Practice Address - Country:US
Practice Address - Phone:910-532-4805
Practice Address - Fax:910-532-4805
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-082-017261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care