Basic Information
| Provider Information | |||||||||
| NPI: | 1003426883 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FENELON | ||||||||
| FirstName: | NATASHA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6675 WESTWOOD BLVD | ||||||||
| Address2: | STE 475 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328216027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078450330 | ||||||||
| FaxNumber: | 8889721752 | ||||||||
| Practice Location | |||||||||
| Address1: | 684 STATE ROAD 60 W | ||||||||
| Address2: | |||||||||
| City: | LAKE WALES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338534419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8639494868 | ||||||||
| FaxNumber: | 8632238549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2020 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11008419 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.