Provider Demographics
NPI:1124664446
Name:PENNER, KAYLA JEAN
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:JEAN
Last Name:PENNER
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 1:370 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-3432
Mailing Address - Country:US
Mailing Address - Phone:707-464-4349
Mailing Address - Fax:
Practice Address - Street 1:6730 LAKE EARL DR
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-7907
Practice Address - Country:US
Practice Address - Phone:707-951-0428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator