Provider Demographics
NPI:1144297771
Name:PENN, JANICE MARION (PHD)
Entity type:Individual
Prefix:DR
First Name:JANICE
Middle Name:MARION
Last Name:PENN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 BARBARA LOOP SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1009
Mailing Address - Country:US
Mailing Address - Phone:505-892-3639
Mailing Address - Fax:505-892-6348
Practice Address - Street 1:4101 BARBARA LOOP SE
Practice Address - Street 2:SUITE D
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1009
Practice Address - Country:US
Practice Address - Phone:505-892-3639
Practice Address - Fax:505-892-6348
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR14768364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM98648Medicaid
NM331332404Medicare ID - Type UnspecifiedPROVIDER NUMBER
NMR13248Medicare UPIN