Individual
GAIL HERNDON FENNIMORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
4012 PARK RD, SUITE 200, CHARLOTTE, NC 28209-2377
(704) 332-4834
(704) 372-9653
Mailing address
4012 PARK RD, SUITE 200, CHARLOTTE, NC 28209-2377
(704) 332-4834
(704) 372-9653
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
1063
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0103C
BLUE CROSS BLUE SHIELD
NC
01
—
56-1480824
FEDERAL TAX ID
NC
01
—
64-42619
UNITED HEALTHCARE
NC
05
—
7211539
—
NC
Enumeration date
03/24/2006
Last updated
03/07/2013
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