Healthcare Provider Details

I. General information

NPI: 1144755984
Provider Name (Legal Business Name): MRS. JOANNA PENNYWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2181 SHERATON DR
TRENTON MI
48183-1944
US

IV. Provider business mailing address

24635 ETON AVE
DEARBORN HEIGHTS MI
48125-1807
US

V. Phone/Fax

Practice location:
  • Phone: 313-401-6739
  • Fax:
Mailing address:
  • Phone: 313-401-6739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704248741
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: