Provider Demographics
NPI:1710525613
Name:FENNELLY, PETER (DC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:FENNELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 EDGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2358
Mailing Address - Country:US
Mailing Address - Phone:406-471-2498
Mailing Address - Fax:
Practice Address - Street 1:559 EDGEWOOD PL
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2358
Practice Address - Country:US
Practice Address - Phone:406-471-2498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTCHI-CHI-LIC-6130111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty