Provider Demographics
NPI:1982326518
Name:FOVENYESSY, CAITLIN
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:FOVENYESSY
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 1:1220 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-2730
Mailing Address - Country:US
Mailing Address - Phone:650-339-1312
Mailing Address - Fax:
Practice Address - Street 1:20823 STEVENS CREEK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-2112
Practice Address - Country:US
Practice Address - Phone:408-252-6076
Practice Address - Fax:408-252-1159
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302831208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA302831OtherPHYSICAL THERAPY CA LICENSE