Healthcare Provider Details

I. General information

NPI: 1144297771
Provider Name (Legal Business Name): JANICE MARION PENN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 BARBARA LOOP SE SUITE D
RIO RANCHO NM
87124-1009
US

IV. Provider business mailing address

4101 BARBARA LOOP SE SUITE D
RIO RANCHO NM
87124-1009
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-3639
  • Fax: 505-892-6348
Mailing address:
  • Phone: 505-892-3639
  • Fax: 505-892-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberR14768
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: