Provider Demographics
NPI:1336347491
Name:FENNELLY, WENDY C (PA-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:C
Last Name:FENNELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 BLACKSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4800
Mailing Address - Country:US
Mailing Address - Phone:401-455-6200
Mailing Address - Fax:401-455-6404
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-455-6200
Practice Address - Fax:401-455-6404
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI64363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI33164-7OtherBCBS
RI414051OtherBLUECHIP
RIWF68506Medicaid
RI414051OtherBLUECHIP