Provider Demographics
NPI:1689482853
Name:FENNELL, DONNA MARIE
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:FENNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9339 CHERRY VALLEY AVE SE UNIT 532
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-0070
Mailing Address - Country:US
Mailing Address - Phone:269-680-1456
Mailing Address - Fax:
Practice Address - Street 1:9339 CHERRY VALLEY AVE SE UNIT 532
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-0070
Practice Address - Country:US
Practice Address - Phone:269-680-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501015130225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist