MEDICARE: MOLLY ANN FENNEMAN MSN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP2201X	Ambulatory Care Registered Nurse	71000271A	IN

General Provider Information

NPI Number	:	1225174048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY ANN FENNEMAN MSN

Provider Business Mailing Address
First Line	:	5430 WASHINGTON BLVD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-3028
Country	:	US
Telephone Number	:	317-252-4831
Fax Number	:	317-252-4831

Provider Business Practice Location Address
First Line	:	200 S MERIDIAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46225-1055
Country	:	US
Telephone Number	:	317-637-4343
Fax Number	:	317-637-4189

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/08/2007

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