Provider Demographics
NPI:1245844950
Name:FENTON, NICHOLLE GLORIA
Entity type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:GLORIA
Last Name:FENTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICHOLLE
Other - Middle Name:GLORIA
Other - Last Name:FENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:448 WILLOW CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-9122
Mailing Address - Country:US
Mailing Address - Phone:412-417-8899
Mailing Address - Fax:
Practice Address - Street 1:448 WILLOW CROSSING RD
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-9122
Practice Address - Country:US
Practice Address - Phone:412-417-8899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG013697225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist