Provider Demographics
NPI:1336381383
Name:PENLAND-ISMATOV, SHERRY LYNN
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:LYNN
Last Name:PENLAND-ISMATOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 LAMB CIR
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-6344
Mailing Address - Country:US
Mailing Address - Phone:540-731-2531
Mailing Address - Fax:540-731-5264
Practice Address - Street 1:2900 LAMB CIR
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-6344
Practice Address - Country:US
Practice Address - Phone:540-731-2531
Practice Address - Fax:540-731-5264
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102-203107207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV6541AOtherMEDICARE PTAN
VAVV6541BOtherMEDICARE PTAN