Provider Demographics
NPI:1194732271
Name:SMITH, PENNIE LOWANDA (PA)
Entity type:Individual
Prefix:MS
First Name:PENNIE
Middle Name:LOWANDA
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:PO BOX 3008
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3008
Mailing Address - Country:US
Mailing Address - Phone:618-734-4400
Mailing Address - Fax:618-477-8557
Practice Address - Street 1:205 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-1256
Practice Address - Country:US
Practice Address - Phone:618-253-8450
Practice Address - Fax:618-253-8454
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2020-10-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL085001576363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant