Healthcare Provider Details

I. General information

NPI: 1992828503
Provider Name (Legal Business Name): ANN M FENN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 REDMOND ST
JACKSON WY
83002
US

IV. Provider business mailing address

PO BOX 14230
JACKSON WY
83002-4230
US

V. Phone/Fax

Practice location:
  • Phone: 307-734-1313
  • Fax: 307-734-0314
Mailing address:
  • Phone: 307-734-0314
  • Fax: 307-734-1313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number5482A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: