Healthcare Provider Details

I. General information

NPI: 1477619377
Provider Name (Legal Business Name): PENNY LOU PHARES ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6210 HARMONY LN
YANKEETOWN FL
34498-2369
US

IV. Provider business mailing address

14 HICKORY AVE
YANKEETOWN FL
34498-2424
US

V. Phone/Fax

Practice location:
  • Phone: 352-447-1775
  • Fax: 352-447-2165
Mailing address:
  • Phone: 352-447-1775
  • Fax: 352-447-2165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberARNP1239672
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: