Provider Demographics
NPI:1679326185
Name:FENTON, MARY THERESA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESA
Last Name:FENTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 CESAR CHAVEZ
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4713
Mailing Address - Country:US
Mailing Address - Phone:415-410-7758
Mailing Address - Fax:
Practice Address - Street 1:169 STEUART ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-1206
Practice Address - Country:US
Practice Address - Phone:415-777-9622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator