Provider Demographics
NPI:1538364955
Name:SKOGLUND, PENNELOPE
Entity type:Individual
Prefix:
First Name:PENNELOPE
Middle Name:
Last Name:SKOGLUND
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:PO BOX 558
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-0558
Mailing Address - Country:US
Mailing Address - Phone:918-207-3000
Mailing Address - Fax:918-207-3076
Practice Address - Street 1:1400 HENSLEY DR
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5221
Practice Address - Country:US
Practice Address - Phone:918-207-3000
Practice Address - Fax:918-207-3076
Is Sole Proprietor?:No
Enumeration Date:2007-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3287101YP2500X
OK79990163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)