Basic Information
| Provider Information | |||||||||
| NPI: | 1194390443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENNELL | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | LILLIAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FENNELL | ||||||||
| OtherFirstName: | MAGGIE | ||||||||
| OtherMiddleName: | LILLIAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | CAMPUS BOX 7593 | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275997593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199663172 | ||||||||
| FaxNumber: | 9199668419 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 KNOX WAY | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275166610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9842054603 | ||||||||
| FaxNumber: | 9842155942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2021 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | FENN-812FG6 | NC | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.