Provider Demographics
NPI:1558683862
Name:FENNELL, MICHELE JEAN (CRNP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:JEAN
Last Name:FENNELL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 NW 33RD AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6349
Mailing Address - Country:US
Mailing Address - Phone:412-779-2101
Mailing Address - Fax:
Practice Address - Street 1:235 ALPHA DR
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15238-2940
Practice Address - Country:US
Practice Address - Phone:877-868-4827
Practice Address - Fax:877-283-0663
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010621363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner