Provider Demographics
NPI:1962765149
Name:WHEELER, PENNY LYNNE (LMT)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:LYNNE
Last Name:WHEELER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5944 MAIN ST
Mailing Address - Street 2:P.O. BOX 82
Mailing Address - City:FROHNA
Mailing Address - State:MO
Mailing Address - Zip Code:63748-8128
Mailing Address - Country:US
Mailing Address - Phone:573-824-5215
Mailing Address - Fax:573-824-1109
Practice Address - Street 1:5944 MAIN ST
Practice Address - Street 2:
Practice Address - City:FROHNA
Practice Address - State:MO
Practice Address - Zip Code:63748-8128
Practice Address - Country:US
Practice Address - Phone:573-824-5215
Practice Address - Fax:573-824-1109
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011039605225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist