Provider Demographics
NPI:1154890333
Name:PENNY, TANNAH LAINE (NURSE AIDE)
Entity type:Individual
Prefix:
First Name:TANNAH
Middle Name:LAINE
Last Name:PENNY
Suffix:
Gender:F
Credentials:NURSE AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:782 S WAVERLY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-1019
Mailing Address - Country:US
Mailing Address - Phone:614-619-9756
Mailing Address - Fax:
Practice Address - Street 1:525 METRO PL N STE 100
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-5343
Practice Address - Country:US
Practice Address - Phone:614-339-0806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-17
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid