Provider Demographics
NPI:1528518602
Name:FENNER, AGNES A
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:A
Last Name:FENNER
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 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2403
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:15 FOUNDERS LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3919
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:217-527-3844
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014954363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily