Provider Demographics
NPI:1487169678
Name:PENN, CHANCELYN S (CNP)
Entity type:Individual
Prefix:
First Name:CHANCELYN
Middle Name:S
Last Name:PENN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 ORLEANS AVE APT 5438
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-4871
Mailing Address - Country:US
Mailing Address - Phone:601-419-7665
Mailing Address - Fax:
Practice Address - Street 1:1520 29TH AVE STE 3
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2843
Practice Address - Country:US
Practice Address - Phone:601-419-7665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-10
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA110298163WG0000X
MS906511363L00000X, 363LP2300X, 363LP0808X
LA227548363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care