Healthcare Provider Details

I. General information

NPI: 1487632535
Provider Name (Legal Business Name): TAMMY JOLENE PENHOLLOW DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2006
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date: 02/18/2010
Reactivation Date: 06/13/2011

III. Provider practice location address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5452
US

IV. Provider business mailing address

18444 N 25TH AVE STE 310
PHOENIX AZ
85023-1266
US

V. Phone/Fax

Practice location:
  • Phone: 480-301-8000
  • Fax:
Mailing address:
  • Phone: 866-974-2673
  • Fax: 866-939-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number005934
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number005934
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: