Provider Demographics
NPI:1962958983
Name:ADAMS, PENELOPE JANE
Entity type:Individual
Prefix:
First Name:PENELOPE
Middle Name:JANE
Last Name:ADAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PENELOPE
Other - Middle Name:JANE
Other - Last Name:NOBLITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27 N REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-3214
Mailing Address - Country:US
Mailing Address - Phone:918-781-3969
Mailing Address - Fax:
Practice Address - Street 1:507 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4215
Practice Address - Country:US
Practice Address - Phone:918-649-0172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator