Healthcare Provider Details

I. General information

NPI: 1821355546
Provider Name (Legal Business Name): MS. LEAH S PENNYBAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

771 CORPORATE DR SUITE 610
LEXINGTON KY
40503-5405
US

IV. Provider business mailing address

PO BOX 910544
LEXINGTON KY
40591-0544
US

V. Phone/Fax

Practice location:
  • Phone: 859-410-8550
  • Fax:
Mailing address:
  • Phone: 859-410-8550
  • Fax: 859-223-0642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number2440914
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: