Provider Demographics
NPI:1124315866
Name:FENNESSEY, SHELLY MARIE
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:MARIE
Last Name:FENNESSEY
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 1:167 SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:CAROGA LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12032
Mailing Address - Country:US
Mailing Address - Phone:518-835-8275
Mailing Address - Fax:
Practice Address - Street 1:234 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1935
Practice Address - Country:US
Practice Address - Phone:518-775-5790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015067225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist