Provider Demographics
NPI:1669907747
Name:FENWICK, PHILLIS
Entity type:Individual
Prefix:
First Name:PHILLIS
Middle Name:
Last Name:FENWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 ELVANS RD SE
Mailing Address - Street 2:APT 202
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-3585
Mailing Address - Country:US
Mailing Address - Phone:202-446-6578
Mailing Address - Fax:
Practice Address - Street 1:2418 ELVANS RD SE
Practice Address - Street 2:APT 202
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3585
Practice Address - Country:US
Practice Address - Phone:202-446-6578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12010374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide