Healthcare Provider Details

I. General information

NPI: 1285543611
Provider Name (Legal Business Name): SORRELL GRACE PENICK BS, SLPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5540 CHESTNUT AVENUE
BUNNELL FL
32110
US

IV. Provider business mailing address

5540 CHESTNUT AVENUE
BUNNELL FL
32110
US

V. Phone/Fax

Practice location:
  • Phone: 931-842-0336
  • Fax:
Mailing address:
  • Phone: 931-842-0336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI9087
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: