Healthcare Provider Details

I. General information

NPI: 1053254128
Provider Name (Legal Business Name): HALEY ELAINE PENKAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 MIAMI VALLEY DR STE 350
CENTERVILLE OH
45459-1294
US

IV. Provider business mailing address

113 FRAHN AVE
FAIRBORN OH
45324-3808
US

V. Phone/Fax

Practice location:
  • Phone: 937-438-8600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.010175RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: