Healthcare Provider Details

I. General information

NPI: 1821669938
Provider Name (Legal Business Name): LORI J PENN MLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 GALLIA ST
PORTSMOUTH OH
45662-4139
US

IV. Provider business mailing address

5439 BURKHARDT RD
DAYTON OH
45431-2111
US

V. Phone/Fax

Practice location:
  • Phone: 740-529-2125
  • Fax:
Mailing address:
  • Phone: 740-876-8290
  • Fax: 740-529-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: