Healthcare Provider Details

I. General information

NPI: 1154537033
Provider Name (Legal Business Name): NANCY PENROD MONNIE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16621 CHAMPION WAY SUITE 100
SANDY OR
97055-7257
US

IV. Provider business mailing address

1711 SE 26TH CT
GRESHAM OR
97080-5291
US

V. Phone/Fax

Practice location:
  • Phone: 503-668-5321
  • Fax: 503-668-9742
Mailing address:
  • Phone: 503-667-5880
  • Fax: 503-669-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1094
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: