Healthcare Provider Details

I. General information

NPI: 1124471545
Provider Name (Legal Business Name): JEFFREY PENNY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8290 OLD TROY PIKE STE 40A
HUBER HEIGHTS OH
45424
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B3
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-4100
  • Fax: 937-208-4107
Mailing address:
  • Phone: 937-991-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.020093
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: