Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 1520 | MA |
NPI | 1194833699 |
---|---|
Provider Name | Dr. Andraea M Fenn |
First Address | Pembroke, MA 02359-1822 |
Second Address | Pembroke, MA 02359-1822 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1610023 | (05) | MA |
U25123 | (02) | MA |