Provider Demographics
NPI:1790366383
Name:FENIMORE, NANCY JEAN
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:JEAN
Last Name:FENIMORE
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 1:15 KINGSLAND AVE
Mailing Address - Street 2:
Mailing Address - City:EAST YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11967-1525
Mailing Address - Country:US
Mailing Address - Phone:631-835-8007
Mailing Address - Fax:
Practice Address - Street 1:121 PULASKI RD
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-2539
Practice Address - Country:US
Practice Address - Phone:631-455-9347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032474225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist