Provider Demographics
NPI:1245871094
Name:FISHENCORD, KERRI ANN (MT)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:ANN
Last Name:FISHENCORD
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 N BALLARD AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-4486
Mailing Address - Country:US
Mailing Address - Phone:214-985-2256
Mailing Address - Fax:
Practice Address - Street 1:311 N BALLARD AVE STE 102
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-4486
Practice Address - Country:US
Practice Address - Phone:214-985-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT044382225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist