Provider Demographics
NPI:1124766738
Name:PENN, PHILIP (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:PENN
Suffix:
Gender:M
Credentials:APRN, FNP-C
Other - Prefix:MR
Other - First Name:PHILIP
Other - Middle Name:TYLER
Other - Last Name:PENN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN, FNP-C
Mailing Address - Street 1:12201 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3300 TATES CREEK RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-3408
Practice Address - Country:US
Practice Address - Phone:859-266-2126
Practice Address - Fax:859-266-5353
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017636363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily