Provider Demographics
NPI:1194751792
Name:FENNEMA, STEPHANIE K (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:K
Last Name:FENNEMA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:KIRKPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4106 COLUMBIA ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907
Mailing Address - Country:US
Mailing Address - Phone:706-863-1440
Mailing Address - Fax:706-863-5418
Practice Address - Street 1:3813 OLD PORT ROYAL RD N
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-2813
Practice Address - Country:US
Practice Address - Phone:931-487-1006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT 9103434363A00000X
GA005416363A00000X
TN3168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292261400Medicaid
FLU6631OtherBCBS FL
FLU6631ZMedicare ID - Type UnspecifiedLINK TO M'CARE GRP 72180
FLU6631XMedicare ID - Type UnspecifiedLINK TO M'CARE GRP 21949
FLU6631YMedicare ID - Type UnspecifiedLINK TO M'CARE GRP 34906
FLQ59986Medicare UPIN
FLU6631VMedicare ID - Type UnspecifiedLINK TO M'CARE GRP 34655
FL292261400Medicaid