Basic Information
| Provider Information | |||||||||
| NPI: | 1891448882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENOFF | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | EVELYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239261171 | ||||||||
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| Practice Location | |||||||||
| Address1: | LAMONT AND VETERANS WAY | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239261171 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2022 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 0000003841 | TN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.