Provider Demographics
NPI:1215055652
Name:PENNELLA, HEIDI COOMER (OTR L)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:COOMER
Last Name:PENNELLA
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18211 CLAY HILL RD
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33523-6476
Mailing Address - Country:US
Mailing Address - Phone:813-404-3232
Mailing Address - Fax:
Practice Address - Street 1:16546 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1325
Practice Address - Country:US
Practice Address - Phone:813-964-8481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10509225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics