Provider Demographics
NPI:1538219811
Name:PENNEWELL, DAPHNE
Entity type:Individual
Prefix:
First Name:DAPHNE
Middle Name:
Last Name:PENNEWELL
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 1:1630 COUNTY ROAD 214
Mailing Address - Street 2:
Mailing Address - City:MONROE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:821 HWY 24
Practice Address - Street 2:SALT RIVER PLAZA
Practice Address - City:MONROE CITY
Practice Address - State:MO
Practice Address - Zip Code:63456-2412
Practice Address - Country:US
Practice Address - Phone:573-735-4113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104949225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist