Provider Demographics
NPI:1154537033
Name:MONNIE, NANCY PENROD (DPT)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:PENROD
Last Name:MONNIE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 SE 26TH CT
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-5291
Mailing Address - Country:US
Mailing Address - Phone:503-667-5880
Mailing Address - Fax:503-669-6555
Practice Address - Street 1:16621 CHAMPION WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-7257
Practice Address - Country:US
Practice Address - Phone:503-668-5321
Practice Address - Fax:503-668-9742
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0308OtherQUAL-MED
OR071787Medicaid
ORC884 X 0OtherPACC
OR86971OtherKAISER
OR0000CFCYXMedicare ID - Type UnspecifiedMEDICARE