Provider Demographics
NPI:1881165371
Name:FENNER, REMANDA (DPT)
Entity type:Individual
Prefix:
First Name:REMANDA
Middle Name:
Last Name:FENNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2997 YAWNOC DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-2508
Mailing Address - Country:US
Mailing Address - Phone:843-450-4602
Mailing Address - Fax:
Practice Address - Street 1:1755 WITTINGTON PL STE 175
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-1905
Practice Address - Country:US
Practice Address - Phone:817-271-6447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist