Provider Demographics
NPI:1194079764
Name:FENECK, MICHELLE AUBRIE (RN, FNP-BC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:AUBRIE
Last Name:FENECK
Suffix:
Gender:F
Credentials:RN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2788 MURFREESBORO PIKE
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-2004
Mailing Address - Country:US
Mailing Address - Phone:714-329-7594
Mailing Address - Fax:
Practice Address - Street 1:2788 MURFREESBORO PIKE
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-2004
Practice Address - Country:US
Practice Address - Phone:714-329-7594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26728363LF0000X
CA822120163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0150193OtherMEDI-CAL