Provider Demographics
NPI:1215709969
Name:FENTRESS, MAURA
Entity type:Individual
Prefix:
First Name:MAURA
Middle Name:
Last Name:FENTRESS
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 1:507 N REID ST
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75979-4501
Mailing Address - Country:US
Mailing Address - Phone:409-429-4389
Mailing Address - Fax:
Practice Address - Street 1:507 N REID ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:TX
Practice Address - Zip Code:75979-4501
Practice Address - Country:US
Practice Address - Phone:409-429-4389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer