Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | DC29506 | CA |
NPI | 1609969120 |
---|---|
Provider Name | Dr. Heidi Susanne Fennell |
First Address | Glendale, CA 91206-4281 |
Second Address | Glendale, CA 91206-4281 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2006 |
Last Update Date | 03/05/2019 |