Provider Demographics
NPI:1780269936
Name:FENWICK, ALEXANDRIA IVONNE
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:IVONNE
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 1:6812 SAO TIAGO WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-3437
Mailing Address - Country:US
Mailing Address - Phone:916-501-4927
Mailing Address - Fax:
Practice Address - Street 1:8801 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3257
Practice Address - Country:US
Practice Address - Phone:916-382-4447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician