Healthcare Provider Details

I. General information

NPI: 1508083759
Provider Name (Legal Business Name): ROSHNEE K PENNINGTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15001 SHADY GROVE RD SUITE #110
ROCKVILLE MD
20850-6352
US

IV. Provider business mailing address

15001 SHADY GROVE RD SUITE #110
ROCKVILLE MD
20850-6352
US

V. Phone/Fax

Practice location:
  • Phone: 301-251-9555
  • Fax: 301-309-0765
Mailing address:
  • Phone: 301-251-9555
  • Fax: 301-309-0765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC02383
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: