Provider Demographics
NPI:1780203745
Name:TRAKTOVENKO, FENELLA (PA-C)
Entity type:Individual
Prefix:
First Name:FENELLA
Middle Name:
Last Name:TRAKTOVENKO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E OLNEY AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2470
Mailing Address - Country:US
Mailing Address - Phone:267-240-5922
Mailing Address - Fax:
Practice Address - Street 1:559 W GERMANTOWN PIKE
Practice Address - Street 2:
Practice Address - City:EAST NORRITON
Practice Address - State:PA
Practice Address - Zip Code:19403-4250
Practice Address - Country:US
Practice Address - Phone:484-622-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant