Healthcare Provider Details

I. General information

NPI: 1861334161
Provider Name (Legal Business Name): PHUNDA LADELL PENNINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9859 FREEDOMS WAY
KEITHVILLE LA
71047-9229
US

IV. Provider business mailing address

9859 FREEDOMS WAY
KEITHVILLE LA
71047-9229
US

V. Phone/Fax

Practice location:
  • Phone: 318-230-3285
  • Fax:
Mailing address:
  • Phone: 318-230-3285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number646
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number646
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: