Provider Demographics
NPI:1699065896
Name:PENNANT, PAULINE PATRICIA
Entity type:Individual
Prefix:
First Name:PAULINE
Middle Name:PATRICIA
Last Name:PENNANT
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 1:1205 ETHANS WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-1710
Mailing Address - Country:US
Mailing Address - Phone:770-865-9153
Mailing Address - Fax:678-833-5973
Practice Address - Street 1:1205 ETHANS WAY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-1710
Practice Address - Country:US
Practice Address - Phone:770-898-2434
Practice Address - Fax:678-833-5973
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-09
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor