Provider Demographics
NPI:1881914232
Name:FENNESSY, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:FENNESSY
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 1:3045 N FEDERAL HWY STE 60H
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1415
Mailing Address - Country:US
Mailing Address - Phone:954-567-8011
Mailing Address - Fax:
Practice Address - Street 1:3045 N FEDERAL HWY STE 60H
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1415
Practice Address - Country:US
Practice Address - Phone:954-567-8011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA56026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist