Healthcare Provider Details

I. General information

NPI: 1336150515
Provider Name (Legal Business Name): ZENE FAWN FENTON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ZENE FAWN GERVAIS OTR/L

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 MENDOCINO AVE STE B
SANTA ROSA CA
95403-3157
US

IV. Provider business mailing address

2360 MENDOCINO AVE A2 #173
SANTA ROSA CA
95403-3153
US

V. Phone/Fax

Practice location:
  • Phone: 707-544-2637
  • Fax: 707-544-2088
Mailing address:
  • Phone: 707-544-2637
  • Fax: 707-544-2088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT2583
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: