Provider Demographics
NPI:1154013795
Name:FENNER, MARYANN (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:FENNER
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 E KINGSTON SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37082-8916
Mailing Address - Country:US
Mailing Address - Phone:615-418-3783
Mailing Address - Fax:
Practice Address - Street 1:112 N RUBEY DR UNIT 135
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80403-3214
Practice Address - Country:US
Practice Address - Phone:303-279-7703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACP030184T225100000X
TN13793225100000X
COCP042448T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist