Provider Demographics
NPI:1790219780
Name:FESSENDEN, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FESSENDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8694 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:MI
Mailing Address - Zip Code:49437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:376 E APPLE AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442
Practice Address - Country:US
Practice Address - Phone:231-724-3699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704312884163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse