Provider Demographics
NPI:1538263645
Name:VINNEDGE, PENNY LYNN (PAC)
Entity type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:LYNN
Last Name:VINNEDGE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:PENNY
Other - Middle Name:LYNN
Other - Last Name:FLEEGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:3F1
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5777
Mailing Address - Country:US
Mailing Address - Phone:715-387-5321
Mailing Address - Fax:715-389-3336
Practice Address - Street 1:1000 N OAK AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449
Practice Address - Country:US
Practice Address - Phone:715-387-9220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WI1724363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41988200Medicaid
WI41988200Medicaid