Provider Demographics
NPI:1063603629
Name:WENDY FENTON
Entity type:Organization
Organization Name:WENDY FENTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:970-769-2166
Mailing Address - Street 1:321 E 37TH ST
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4068
Mailing Address - Country:US
Mailing Address - Phone:970-769-2166
Mailing Address - Fax:
Practice Address - Street 1:321 E 37TH ST
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4068
Practice Address - Country:US
Practice Address - Phone:970-769-2166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3679251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3679OtherARIZONA STATELICENSURE OT