Healthcare Provider Details

I. General information

NPI: 1568440311
Provider Name (Legal Business Name): MS. SUSAN FENNELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 S NEWBURGH RD
WAYNE MI
48184-1002
US

IV. Provider business mailing address

7141 E PARKCREST APT 304
WESTLAND MI
48185-7287
US

V. Phone/Fax

Practice location:
  • Phone: 734-728-6500
  • Fax:
Mailing address:
  • Phone: 866-222-9438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: