Provider Demographics
NPI:1588371850
Name:FENNELL, NICHOLE LYNN
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LYNN
Last Name:FENNELL
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 1:1920 MAIN ST STE 14C
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9472
Mailing Address - Country:US
Mailing Address - Phone:360-366-8398
Mailing Address - Fax:
Practice Address - Street 1:1920 MAIN ST STE 14C
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-9472
Practice Address - Country:US
Practice Address - Phone:360-366-8398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024450225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00024450OtherMASSAGE LICENSE