Provider Demographics
NPI:1871993824
Name:FENNELL, ANGELA JOY (LM, CPM)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:JOY
Last Name:FENNELL
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1468 SW MAIN BLVD STE 105-94
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1115
Mailing Address - Country:US
Mailing Address - Phone:386-288-0698
Mailing Address - Fax:800-853-5087
Practice Address - Street 1:27619 25TH PL
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:FL
Practice Address - Zip Code:32008-2107
Practice Address - Country:US
Practice Address - Phone:386-288-0698
Practice Address - Fax:800-853-5087
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW294176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife