Provider Demographics
NPI:1477846582
Name:FENNELL, STACY LYNN (DO)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:FENNELL
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 1:8344 VERSAILLES SE RD
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45308-9602
Mailing Address - Country:US
Mailing Address - Phone:937-974-8352
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DR
Practice Address - Street 2:MCHE-EMR
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4501
Practice Address - Country:US
Practice Address - Phone:210-292-7626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004134A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice