Individual
DR. RISHA RAVEN FENNELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
2501 CHATHAM RD STE 4713, SPRINGFIELD, IL 62704-4188
(779) 429-2227
Mailing address
900 BEECH ST, NORMAL, IL 61761-1803
(779) 429-2227
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
036100518
IL
207QA0401X
Addiction Medicine (Family Medicine) Physician
Primary
036100518
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036100518
—
IL
Enumeration date
03/08/2006
Last updated
06/07/2024
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