Healthcare Provider Details

I. General information

NPI: 1417117664
Provider Name (Legal Business Name): PENNY XUAN DUPRE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10075 GRAND BAY WILMER RD S
GRAND BAY AL
36541-5003
US

IV. Provider business mailing address

10075 GRAND BAY WILMER RD S
GRAND BAY AL
36541-5003
US

V. Phone/Fax

Practice location:
  • Phone: 251-865-1852
  • Fax:
Mailing address:
  • Phone: 251-865-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.203001
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: