Provider Demographics
NPI:1508068446
Name:FENNELLY, JOANNA ROSE (AUD)
Entity Type:Individual
Prefix:MS
First Name:JOANNA
Middle Name:ROSE
Last Name:FENNELLY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-2133
Mailing Address - Country:US
Mailing Address - Phone:248-321-0075
Mailing Address - Fax:
Practice Address - Street 1:2421 MONROE ST STE 202
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3043
Practice Address - Country:US
Practice Address - Phone:313-562-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000465231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist