Healthcare Provider Details

I. General information

NPI: 1104734441
Provider Name (Legal Business Name): EMILY DAWN FENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13765 VINTAGE DR SW
PORT ORCHARD WA
98367-7391
US

IV. Provider business mailing address

321 NE FAIRGROUNDS RD APT D203
BREMERTON WA
98311-9282
US

V. Phone/Fax

Practice location:
  • Phone: 971-203-4318
  • Fax:
Mailing address:
  • Phone: 971-203-4318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: