Provider Demographics
NPI:1124698022
Name:PENNO, SARA JOHANNA (MS)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:JOHANNA
Last Name:PENNO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 W CLEVELAND ST UNIT D10
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3182
Mailing Address - Country:US
Mailing Address - Phone:262-323-4434
Mailing Address - Fax:
Practice Address - Street 1:206 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4617
Practice Address - Country:US
Practice Address - Phone:813-662-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10158235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10158Medicaid