Provider Demographics
NPI:1467808923
Name:FONVILLE, DONNELL
Entity Type:Individual
Prefix:
First Name:DONNELL
Middle Name:
Last Name:FONVILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4137 WOODFIELD RD
Mailing Address - Street 2:
Mailing Address - City:N CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234
Mailing Address - Country:US
Mailing Address - Phone:804-229-5353
Mailing Address - Fax:804-859-7921
Practice Address - Street 1:4137 WOODFIELD RD
Practice Address - Street 2:
Practice Address - City:N CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23234
Practice Address - Country:US
Practice Address - Phone:804-229-5353
Practice Address - Fax:804-859-7921
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA267172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver