Provider Demographics
NPI:1891056669
Name:FENN, AMY M (BSW)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:M
Last Name:FENN
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 NYE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-9133
Mailing Address - Country:US
Mailing Address - Phone:315-946-5749
Mailing Address - Fax:
Practice Address - Street 1:1519 NYE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-9133
Practice Address - Country:US
Practice Address - Phone:315-946-5749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355899Medicaid
NY3001970Medicaid