Provider Demographics
NPI:1720445463
Name:PENNINGTON, THERESA LOUISE (FNP-BC)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:LOUISE
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14030 HIGHWAY 160
Mailing Address - Street 2:
Mailing Address - City:HARVIELL
Mailing Address - State:MO
Mailing Address - Zip Code:63945-8161
Mailing Address - Country:US
Mailing Address - Phone:573-714-4228
Mailing Address - Fax:
Practice Address - Street 1:3100 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1573
Practice Address - Country:US
Practice Address - Phone:573-776-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016001340363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily