Healthcare Provider Details

I. General information

NPI: 1144243692
Provider Name (Legal Business Name): TIMOTHY R PENNISTON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2352 QUARTER HORSE TRL
OVERGAARD AZ
85933-5319
US

IV. Provider business mailing address

825 N GRAND AVE STE 100
NOGALES AZ
85621-1061
US

V. Phone/Fax

Practice location:
  • Phone: 928-535-3616
  • Fax: 928-532-2156
Mailing address:
  • Phone: 520-281-1550
  • Fax: 520-281-2335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP3433
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: