Healthcare Provider Details

I. General information

NPI: 1356606768
Provider Name (Legal Business Name): MISTY MARIE PENROD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISTY MARIE MARTIN FNP-C

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 PROGRESSIVE ST
BLUFFTON SC
29910-5165
US

IV. Provider business mailing address

1053 CENTER STREET SC HOUSE CALLS INC
WEST COLUMBIA SC
29169-1873
US

V. Phone/Fax

Practice location:
  • Phone: 843-548-0533
  • Fax: 843-815-9121
Mailing address:
  • Phone: 800-491-0909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN.251801-COA1
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number251801
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23137
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: