Healthcare Provider Details

I. General information

NPI: 1952858797
Provider Name (Legal Business Name): KYLE FENNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E DUBLIN GRANVILLE RD
WORTHINGTON OH
43085-3192
US

IV. Provider business mailing address

445 E DUBLIN GRANVILLE RD
WORTHINGTON OH
43085-3192
US

V. Phone/Fax

Practice location:
  • Phone: 614-844-3800
  • Fax: 614-431-8129
Mailing address:
  • Phone: 614-844-3800
  • Fax: 614-431-8129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004794RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: