1609279314 NPI number — MRS. PENNY L HOUSEMAN NP-C

Table of content: MRS. PENNY L HOUSEMAN NP-C (NPI 1609279314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609279314 NPI number — MRS. PENNY L HOUSEMAN NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOUSEMAN
Provider First Name:
PENNY
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP-C
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:
1609279314
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
227 SE 43RD TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE CORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33904-8424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-738-8311
Provider Business Mailing Address Fax Number:
239-778-9789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 SE 43RD TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE CORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33904-8424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-738-8311
Provider Business Practice Location Address Fax Number:
239-778-9789
Provider Enumeration Date:
10/08/2014

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: 363LF0000X , with the licence number:  71005194A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APRN11011390 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201258910 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000899250 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 0117645 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116109500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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