Healthcare Provider Details

I. General information

NPI: 1023285863
Provider Name (Legal Business Name): ROBERT FENNELL ATC, M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 VALPARAISO AVE
ATHERTON CA
94027-4402
US

IV. Provider business mailing address

150 VALPARAISO AVE
ATHERTON CA
94027-4402
US

V. Phone/Fax

Practice location:
  • Phone: 650-473-4035
  • Fax:
Mailing address:
  • Phone: 650-473-4035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.002601
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: