Provider Demographics
NPI:1588632293
Name:FANDEL, DENISE (AT RET)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:FANDEL
Suffix:
Gender:F
Credentials:AT RET
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 N 124TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-2573
Mailing Address - Country:US
Mailing Address - Phone:402-651-5088
Mailing Address - Fax:
Practice Address - Street 1:1415 HARNEY ST
Practice Address - Street 2:SUITE
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-2250
Practice Address - Country:US
Practice Address - Phone:402-559-0091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16235500000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist