Provider Demographics
NPI:1487083978
Name:FENNESSEY, AVALON DIBNER (CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:AVALON
Middle Name:DIBNER
Last Name:FENNESSEY
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:MISS
Other - First Name:AVALON
Other - Middle Name:BEDFORD
Other - Last Name:DIBNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP-PC
Mailing Address - Street 1:120 CONNECTICUT AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-1525
Mailing Address - Country:US
Mailing Address - Phone:203-899-1770
Mailing Address - Fax:
Practice Address - Street 1:120 CONNECTICUT AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06854-1525
Practice Address - Country:US
Practice Address - Phone:203-899-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT113331163W00000X
DEL1-0042593163W00000X
MERN61411163W00000X
PARN634654163W00000X
CT5598363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse