Healthcare Provider Details

I. General information

NPI: 1518448307
Provider Name (Legal Business Name): MICHELLE RUTH PENNO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13430 N SCOTTSDALE RD STE 200
SCOTTSDALE AZ
85254-4058
US

IV. Provider business mailing address

6677 W THUNDERBIRD RD STE C142
GLENDALE AZ
85306-3760
US

V. Phone/Fax

Practice location:
  • Phone: 888-407-7928
  • Fax:
Mailing address:
  • Phone: 480-963-1853
  • Fax: 602-973-0978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP11242
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: