Healthcare Provider Details

I. General information

NPI: 1316928807
Provider Name (Legal Business Name): DEBRA K. FENTON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 OLD LUCERNE RD
UPPER LAKE CA
95485-8755
US

IV. Provider business mailing address

5516 OAK RIDGE DR
KELSEYVILLE CA
95451-9374
US

V. Phone/Fax

Practice location:
  • Phone: 707-275-9066
  • Fax: 707-275-9070
Mailing address:
  • Phone: 707-279-4489
  • Fax: 707-275-9066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number332923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: