1336150515 NPI number — MRS. ZENE FAWN FENTON OTR/L

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336150515 NPI number — MRS. ZENE FAWN FENTON OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FENTON
Provider First Name:
ZENE
Provider Middle Name:
FAWN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GERVAIS
Provider Other First Name:
ZENE
Provider Other Middle Name:
FAWN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336150515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2360 MENDOCINO AVE
Provider Second Line Business Mailing Address:
A2 #173
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95403-3153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-544-2637
Provider Business Mailing Address Fax Number:
707-544-2088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2305 MENDOCINO AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95403-3157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-544-2637
Provider Business Practice Location Address Fax Number:
707-544-2088
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XH1200X , with the licence number:  OT2583 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OT-0025830 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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