Provider Demographics
NPI:1063939403
Name:FENELON, TARESA (NP-C)
Entity type:Individual
Prefix:MRS
First Name:TARESA
Middle Name:
Last Name:FENELON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TARESA
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:1003 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-5419
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:
Practice Address - Street 1:1003 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-5419
Practice Address - Country:US
Practice Address - Phone:832-795-3593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134969363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily