Healthcare Provider Details

I. General information

NPI: 1215234778
Provider Name (Legal Business Name): MRS. PENNY ANN MEDICINEBEAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 02/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 SUNSET AVE
SMITHS GROVE KY
41217
US

IV. Provider business mailing address

PO BOX 433
SMITHS GROVE KY
42171-0433
US

V. Phone/Fax

Practice location:
  • Phone: 270-784-7079
  • Fax:
Mailing address:
  • Phone: 270-784-7079
  • Fax: 270-451-1200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number3585
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number3586
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: