1154537033 NPI number — DR. NANCY PENROD MONNIE DPT

Table of content: (NPI 1174769384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154537033 NPI number — DR. NANCY PENROD MONNIE DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONNIE
Provider First Name:
NANCY
Provider Middle Name:
PENROD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154537033
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1711 SE 26TH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRESHAM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97080-5291
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-667-5880
Provider Business Mailing Address Fax Number:
503-669-6555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16621 CHAMPION WAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SANDY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97055-7257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-668-5321
Provider Business Practice Location Address Fax Number:
503-668-9742
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1094 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0308 . This is a "QUAL-MED" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 071787 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: C884 X 0 . This is a "PACC" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 86971 . This is a "KAISER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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