Provider Demographics
NPI:1164254868
Name:PENICHE, JOHANN MARCELINO
Entity type:Individual
Prefix:
First Name:JOHANN
Middle Name:MARCELINO
Last Name:PENICHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 BENTGRASS DR
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-3958
Mailing Address - Country:US
Mailing Address - Phone:580-583-3907
Mailing Address - Fax:
Practice Address - Street 1:12 MEDSTAR BLVD STE 255
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-1798
Practice Address - Country:US
Practice Address - Phone:580-583-3907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program