Healthcare Provider Details

I. General information

NPI: 1780116178
Provider Name (Legal Business Name): ANDREA PENTON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MANNING DR #1072 EAST WING
CHAPEL HILL NC
27514-4220
US

IV. Provider business mailing address

15 INDIGO CREEK TRL #1072 EAST WING
DURHAM NC
27712-2564
US

V. Phone/Fax

Practice location:
  • Phone: 984-974-1790
  • Fax:
Mailing address:
  • Phone: 919-309-7195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number2013139
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: