Healthcare Provider Details

I. General information

NPI: 1487644290
Provider Name (Legal Business Name): JENNIFER NICOLE PENNINGTON TAYLOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER NICOLE PENNINGTON PA-C

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 TERRACE STREET
HINTON WV
25951
US

IV. Provider business mailing address

1500 TERRACE STREET PO BOX 940
HINTON WV
25951
US

V. Phone/Fax

Practice location:
  • Phone: 304-466-2905
  • Fax: 304-466-2917
Mailing address:
  • Phone: 304-466-2905
  • Fax: 304-466-2917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number01014
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: