Healthcare Provider Details

I. General information

NPI: 1275878779
Provider Name (Legal Business Name): GINA MARIE PENKA CORRIVEAU CPM, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GINA MARIE PENKA CPM, IBCLC

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 PINEWOODS RD
LISBON ME
04250-6247
US

IV. Provider business mailing address

6 PINEWOODS RD
LISBON ME
04250-6247
US

V. Phone/Fax

Practice location:
  • Phone: 720-319-0135
  • Fax: 720-319-0135
Mailing address:
  • Phone: 720-319-0135
  • Fax: 720-319-0135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: