Healthcare Provider Details

I. General information

NPI: 1255704441
Provider Name (Legal Business Name): LORI PENNOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MURRAY CT
ROCKVILLE CTR NY
11570-6010
US

IV. Provider business mailing address

5 MURRAY CT
ROCKVILLE CTR NY
11570-6010
US

V. Phone/Fax

Practice location:
  • Phone: 516-582-8079
  • Fax:
Mailing address:
  • Phone: 516-582-8079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: