Healthcare Provider Details

I. General information

NPI: 1346232022
Provider Name (Legal Business Name): HOLLY PENNINGTON MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY BROOKS MPT

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8910 184TH AVE E
BONNEY LAKE WA
98391-8531
US

IV. Provider business mailing address

26837 MAPLE VALLEY BLACK DIAMOND RD SE STE 200
MAPLE VALLEY WA
98038-9917
US

V. Phone/Fax

Practice location:
  • Phone: 253-863-7510
  • Fax: 253-863-5970
Mailing address:
  • Phone: 425-413-4427
  • Fax: 425-413-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00008860
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: