Provider Demographics
NPI:1124708425
Name:FENLEY, NICHOLE LAUREAL
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LAUREAL
Last Name:FENLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:LAUREAL
Other - Last Name:MATHEWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2511 PYRENEES AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3268
Mailing Address - Country:US
Mailing Address - Phone:209-888-7852
Mailing Address - Fax:
Practice Address - Street 1:1212 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1552
Practice Address - Country:US
Practice Address - Phone:209-468-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker