Provider Demographics
NPI:1588874606
Name:PENICK, PATRICIA LOUISE (PT)
Entity type:Individual
Prefix:MISS
First Name:PATRICIA
Middle Name:LOUISE
Last Name:PENICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 WISTERIA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-1150
Mailing Address - Country:US
Mailing Address - Phone:619-223-0400
Mailing Address - Fax:619-223-0400
Practice Address - Street 1:3508 WISTERIA DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-1150
Practice Address - Country:US
Practice Address - Phone:619-223-0400
Practice Address - Fax:619-223-0400
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 16717174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist