Healthcare Provider Details

I. General information

NPI: 1558641118
Provider Name (Legal Business Name): KELLY A FENN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY A WITTLER

II. Dates (important events)

Enumeration Date: 08/26/2011
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

988102 NEBRASKA MEDICAL CTR
OMAHA NE
68198-8102
US

IV. Provider business mailing address

988102 NEBRASKA MEDICAL CTR
OMAHA NE
68198-8102
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-4017
  • Fax: 402-559-6749
Mailing address:
  • Phone: 402-559-4017
  • Fax: 402-559-6749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1603
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: