Healthcare Provider Details

I. General information

NPI: 1720785587
Provider Name (Legal Business Name): MRS. ABIGAIL PENICHET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W ORANGE ST
LAKELAND FL
33815-4645
US

IV. Provider business mailing address

3909 CHARLIE TAYLOR RD
PLANT CITY FL
33565-2529
US

V. Phone/Fax

Practice location:
  • Phone: 813-344-9956
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11025612
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9424455
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: