Provider Demographics
NPI:1063078574
Name:PENROD, EMMA ELAINE (PT, DPT)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:ELAINE
Last Name:PENROD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13937 S SPRAGUE LN STE 100
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7864
Mailing Address - Country:US
Mailing Address - Phone:385-308-8034
Mailing Address - Fax:
Practice Address - Street 1:13937 S SPRAGUE LN STE 100
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7864
Practice Address - Country:US
Practice Address - Phone:385-308-8034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT031999225100000X
KS11-06316225100000X
NY052144225100000X
MO2019030129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist