Individual
NICOLE FENNELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1775 THOMPSON RD, COOS BAY, OR 97420-2125
(541) 269-8111
Mailing address
1775 THOMPSON RD, COOS BAY, OR 97420-2125
(541) 269-8111
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA179333
OR
Other
Enumeration date
09/06/2016
Last updated
09/06/2016
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