Provider Demographics
NPI:1992785505
Name:WALTMAN, PENNY L (CNM)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:L
Last Name:WALTMAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:STE M351, BRONSON WOMENS SERVICES
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007
Practice Address - Country:US
Practice Address - Phone:269-341-7979
Practice Address - Fax:269-341-6261
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4704112162367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3073870Medicaid
MI3073870Medicaid