Healthcare Provider Details

I. General information

NPI: 1912905035
Provider Name (Legal Business Name): JAMES ASHLEY FENNELL II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2084 N 1700 W SUITE A
LAYTON UT
84041
US

IV. Provider business mailing address

2086 N 1700 W SUITE C
LAYTON UT
84041
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-8644
  • Fax: 801-773-9828
Mailing address:
  • Phone: 801-773-8644
  • Fax: 801-927-1591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number186237-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: