Provider Demographics
NPI:1104260413
Name:PENKALA, MARY ELIZABETH (CNS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:PENKALA
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6847 N CHESTNUT ST STE 115
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3929
Mailing Address - Country:US
Mailing Address - Phone:330-297-6055
Mailing Address - Fax:330-297-4918
Practice Address - Street 1:6847 N CHESTNUT ST STE 115
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3929
Practice Address - Country:US
Practice Address - Phone:330-297-6055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNS.01044364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0083512Medicaid