Healthcare Provider Details

I. General information

NPI: 1518128909
Provider Name (Legal Business Name): KIRSTEN N PENNELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4092 FOXWOOD DR. STE 101
VA BEACH VA
23462-5225
US

IV. Provider business mailing address

P.O. BOX 7549
PORTSMOUTH VA
23707-0549
US

V. Phone/Fax

Practice location:
  • Phone: 757-467-4200
  • Fax: 757-686-0541
Mailing address:
  • Phone: 757-686-3525
  • Fax: 757-686-0541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116018438
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101245787
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: