Provider Demographics
NPI:1962745315
Name:PENKAVA, LAURA KETTLE (CRNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KETTLE
Last Name:PENKAVA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 GRAN AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209
Mailing Address - Country:US
Mailing Address - Phone:256-694-4288
Mailing Address - Fax:
Practice Address - Street 1:7191 CAHABA VALLEY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-6402
Practice Address - Country:US
Practice Address - Phone:205-995-9909
Practice Address - Fax:205-930-2063
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-126161363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-126161OtherCRNP