Provider Demographics
NPI:1144094442
Name:PENNY, LATRICE
Entity type:Individual
Prefix:
First Name:LATRICE
Middle Name:
Last Name:PENNY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12163 OLD SALEM CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-6258
Mailing Address - Country:US
Mailing Address - Phone:410-297-1821
Mailing Address - Fax:
Practice Address - Street 1:12163 OLD SALEM CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-6258
Practice Address - Country:US
Practice Address - Phone:410-297-1821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP500488368942172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver