Provider Demographics
NPI:1104226422
Name:PENN, ASHLEY
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:PENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 HARRINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-9496
Mailing Address - Country:US
Mailing Address - Phone:270-304-4059
Mailing Address - Fax:
Practice Address - Street 1:55 HARRINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-9496
Practice Address - Country:US
Practice Address - Phone:270-304-4059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201155315171M00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator