1518247758 NPI number — PENNY J MADER CNP

Table of content: PENNY J MADER CNP (NPI 1518247758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518247758 NPI number — PENNY J MADER CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADER
Provider First Name:
PENNY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
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:
1518247758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1055 N 500 W
Provider Second Line Business Mailing Address:
ATTN CREDENTIALING
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604-4232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-354-8225
Provider Business Mailing Address Fax Number:
801-418-0941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1055 N 500 W
Provider Second Line Business Practice Location Address:
ATTN CREDENTIALING
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-354-8225
Provider Business Practice Location Address Fax Number:
801-418-0941
Provider Enumeration Date:
08/19/2011

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: 363L00000X , with the licence number:  13327156-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: CNP-01828 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 48922218 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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