Healthcare Provider Details

I. General information

NPI: 1447831730
Provider Name (Legal Business Name): MISTY DAWN PENNINGTON APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 NORTH CLYDE MORRIS BLVD SUITE 320
DAYTONA BEACH FL
32114
US

IV. Provider business mailing address

725 FREDA LN
PORT ORANGE FL
32127-5931
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-5331
  • Fax: 386-255-3723
Mailing address:
  • Phone: 386-527-1939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11011414
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: