Healthcare Provider Details

I. General information

NPI: 1528754900
Provider Name (Legal Business Name): ANNALYN PENKALA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 S GREEN ST
TUPELO MS
38804-6556
US

IV. Provider business mailing address

271 FONDERLAC DR SE
WARREN OH
44484-2158
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-2261
  • Fax:
Mailing address:
  • Phone: 330-979-9632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34926
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: