Healthcare Provider Details

I. General information

NPI: 1922569748
Provider Name (Legal Business Name): NICOLE JENE FENNIMORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 WINNEBAGO ST
MADISON WI
53704-5341
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-914-2200
  • Fax: 608-245-6117
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD205498
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number87424-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: