Provider Demographics
NPI:1912199894
Name:FENDER, DONNA E (PT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:E
Last Name:FENDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-1918
Mailing Address - Country:US
Mailing Address - Phone:252-541-1941
Mailing Address - Fax:866-521-3780
Practice Address - Street 1:310 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-1918
Practice Address - Country:US
Practice Address - Phone:252-678-4065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212307Medicaid
NCQ36782CMedicare PIN