Provider Demographics
NPI:1255028262
Name:FENNELL, MARY KATHERINE (APN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:FENNELL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHERINE
Other - Last Name:SHEETS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:222 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1852
Mailing Address - Country:US
Mailing Address - Phone:629-255-3486
Mailing Address - Fax:629-255-3075
Practice Address - Street 1:1620 WESTGATE CIR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-8035
Practice Address - Country:US
Practice Address - Phone:629-255-2271
Practice Address - Fax:629-255-4279
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37653363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN37653OtherAPN LICENSE
TNQ098661Medicaid