Healthcare Provider Details

I. General information

NPI: 1841428182
Provider Name (Legal Business Name): ASHLEY B PENN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 08/27/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

NAVY MEDICINE SUPPORT COMMAND BLDG H 2005 KNIGHT LANE ATTN: MEDICAL STAFF SERVICES
JACKSONVILLE FL
32212-0140
US

V. Phone/Fax

Practice location:
  • Phone: 415-513-2719
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01071247A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: