Provider Demographics
NPI:1770166118
Name:FENNEMA, RACHEL (DO)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:FENNEMA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 LINCOLN WAY STE 315
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2527
Mailing Address - Country:US
Mailing Address - Phone:208-625-6000
Mailing Address - Fax:
Practice Address - Street 1:9348 E RITA RD STE 140
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85747-6301
Practice Address - Country:US
Practice Address - Phone:520-324-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ011265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program