Healthcare Provider Details

I. General information

NPI: 1124119458
Provider Name (Legal Business Name): DAVID KENNETH FENNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 W ELK AVE SUITE 2
ELIZABETHTON TN
37643-2848
US

IV. Provider business mailing address

1505 W ELK AVE SUITE 2
ELIZABETHTON TN
37643-2848
US

V. Phone/Fax

Practice location:
  • Phone: 423-543-1261
  • Fax: 423-543-7500
Mailing address:
  • Phone: 423-543-1261
  • Fax: 423-543-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License NumberMD0000008020
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number8020
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: