Provider Demographics
NPI:1619376274
Name:FENNELL, NICOLE S (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:FENNELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1928
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3022
Mailing Address - Country:US
Mailing Address - Phone:334-712-3635
Mailing Address - Fax:334-699-4387
Practice Address - Street 1:1108 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3022
Practice Address - Country:US
Practice Address - Phone:334-712-3635
Practice Address - Fax:334-699-4387
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-120271363L00000X
FLARNP9382028363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner