Provider Demographics
NPI:1073076311
Name:FENNELL, HEATHER LYNN (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:FENNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEALTHER
Other - Middle Name:LYNN
Other - Last Name:MINTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4000 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670-2000
Mailing Address - Country:US
Mailing Address - Phone:448-321-9568
Mailing Address - Fax:989-633-5241
Practice Address - Street 1:4201 CAMPUS RIDGE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6128
Practice Address - Country:US
Practice Address - Phone:989-837-9071
Practice Address - Fax:989-488-5783
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301514883208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program