Provider Demographics
NPI:1467628784
Name:FENNELL, SHEILA RENEE
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:RENEE
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 1:309 AVENUE F
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-1421
Mailing Address - Country:US
Mailing Address - Phone:850-229-8280
Mailing Address - Fax:
Practice Address - Street 1:309 AVENUE F
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1421
Practice Address - Country:US
Practice Address - Phone:850-229-8280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693532096Medicaid