Provider Demographics
NPI:1215091012
Name:PENNA, PATRICIA E (RN)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:E
Last Name:PENNA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 TULIP GROVE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1821
Mailing Address - Country:US
Mailing Address - Phone:631-981-0704
Mailing Address - Fax:
Practice Address - Street 1:14 TULIP GROVE DR
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1821
Practice Address - Country:US
Practice Address - Phone:631-981-0704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY371523-1163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01109897Medicaid