Healthcare Provider Details

I. General information

NPI: 1245669738
Provider Name (Legal Business Name): KIMBERLY FEZELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY CLUTE

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 W 23RD ST SUITE 1
ERIE PA
16506-5802
US

IV. Provider business mailing address

4950 W 23RD ST SUITE 1
ERIE PA
16506-5802
US

V. Phone/Fax

Practice location:
  • Phone: 814-459-2755
  • Fax:
Mailing address:
  • Phone: 814-459-2755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC007134
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: