Healthcare Provider Details

I. General information

NPI: 1710944863
Provider Name (Legal Business Name): PENNI LORRAINE CREMER PMHCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PENNI LORRAINE FUQUA PMHCNS-BC

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 E 91ST ST
INDIANAPOLIS IN
46240-1902
US

IV. Provider business mailing address

12539 PEBBLEPOINTE PASS
CARMEL IN
46033
US

V. Phone/Fax

Practice location:
  • Phone: 317-709-3365
  • Fax:
Mailing address:
  • Phone: 317-709-3365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number70000131A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: