Provider Demographics
NPI:1699818443
Name:FENWICK, MARY P (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:P
Last Name:FENWICK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7818
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:110 S SALEM DR
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004
Practice Address - Country:US
Practice Address - Phone:502-349-4745
Practice Address - Fax:502-348-3400
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4707P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0921096Medicare PIN
KY0631255Medicare PIN
KYQ62986Medicare UPIN
KY0523950Medicare PIN