Healthcare Provider Details

I. General information

NPI: 1558400788
Provider Name (Legal Business Name): RAFFAELE PENNELLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 S GREYSTONE CT
SPRINGFIELD MO
65804
US

IV. Provider business mailing address

3808 S GREYSTONE CT
SPRINGFIELD MO
65804
US

V. Phone/Fax

Practice location:
  • Phone: 417-889-3332
  • Fax: 417-881-1410
Mailing address:
  • Phone: 417-889-3332
  • Fax: 417-881-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number110288
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: