Healthcare Provider Details

I. General information

NPI: 1275096158
Provider Name (Legal Business Name): RICHELLE PATRICIA PENNINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 BEATTY DR
BELMONT NC
28012-2715
US

IV. Provider business mailing address

275 BEATTY DR
BELMONT NC
28012-2715
US

V. Phone/Fax

Practice location:
  • Phone: 704-822-2550
  • Fax:
Mailing address:
  • Phone: 704-822-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001011689
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number023671
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: