Provider Demographics
NPI:1538422274
Name:PENNICOOKE, DWAYNE A (MSED)
Entity type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:A
Last Name:PENNICOOKE
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4828 OSGOOD ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470-1021
Mailing Address - Country:US
Mailing Address - Phone:914-290-9041
Mailing Address - Fax:
Practice Address - Street 1:4828 OSGOOD ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10470-1021
Practice Address - Country:US
Practice Address - Phone:914-290-9041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY811870174400000X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No252Y00000XAgenciesEarly Intervention Provider Agency