Provider Demographics
NPI:1649262429
Name:FENNELLY, KATHLEEN MARIE (RN, NP,)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:FENNELLY
Suffix:
Gender:F
Credentials:RN, NP,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:896 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1761
Mailing Address - Country:US
Mailing Address - Phone:805-542-0900
Mailing Address - Fax:
Practice Address - Street 1:896 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1761
Practice Address - Country:US
Practice Address - Phone:805-542-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7319363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA456414OtherRN LICENSE #
CA7319OtherNP LICENSE #