Provider Demographics
NPI:1689366486
Name:FENN, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:FENN
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 1:18697 BAGLEY RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3417
Mailing Address - Country:US
Mailing Address - Phone:440-816-6051
Mailing Address - Fax:
Practice Address - Street 1:18697 BAGLEY RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-3417
Practice Address - Country:US
Practice Address - Phone:440-816-6051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0033875363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner