Healthcare Provider Details

I. General information

NPI: 1083788780
Provider Name (Legal Business Name): JULIE LYNN PENTON CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 WILLAGILLESPIE RD SUITE #100
EUGENE OR
97401-2186
US

IV. Provider business mailing address

1456 COTTONWOOD AVE
SPRINGFIELD OR
97477-7617
US

V. Phone/Fax

Practice location:
  • Phone: 541-484-5437
  • Fax:
Mailing address:
  • Phone: 541-741-8633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number000041824N2 PNP-PP
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: