Healthcare Provider Details

I. General information

NPI: 1154685444
Provider Name (Legal Business Name): PENNY PARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 9TH AVENUE CIR S
FARGO ND
58103-2090
US

IV. Provider business mailing address

4234 9TH AVENUE CIR S
FARGO ND
58103-2090
US

V. Phone/Fax

Practice location:
  • Phone: 701-429-4874
  • Fax:
Mailing address:
  • Phone: 701-429-4874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number1524-586-731
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: