Provider Demographics
NPI:1528294857
Name:PENNICKARA, SHEEBA
Entity type:Individual
Prefix:
First Name:SHEEBA
Middle Name:
Last Name:PENNICKARA
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 1:4285 PATRICK AVE.
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N9G 2X8
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4285 PATRICK AVE.
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:ONTARIO
Practice Address - Zip Code:N9G 2X8
Practice Address - Country:CA
Practice Address - Phone:519-250-0872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005433363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant