Healthcare Provider Details

I. General information

NPI: 1295556884
Provider Name (Legal Business Name): CHANDELLE DOREEN FETNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E FRONT ST
DE KALB TX
75559-1464
US

IV. Provider business mailing address

303 N CENTER ST
NEW BOSTON TX
75570-2918
US

V. Phone/Fax

Practice location:
  • Phone: 903-667-7000
  • Fax:
Mailing address:
  • Phone: 903-628-7700
  • Fax: 903-628-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2162087
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: