Healthcare Provider Details

I. General information

NPI: 1275202095
Provider Name (Legal Business Name): COURTNEY BROOKE PENN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

11835 FISHING POINT DR STE 104
NEWPORT NEWS VA
23606-2584
US

IV. Provider business mailing address

PO BOX 5508
VIRGINIA BEACH VA
23471-0508
US

V. Phone/Fax

Practice location:
  • Phone: 757-599-5588
  • Fax:
Mailing address:
  • Phone: 757-340-3489
  • Fax: 757-340-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024182616
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: