Healthcare Provider Details

I. General information

NPI: 1376352641
Provider Name (Legal Business Name): TABATHA S PENNINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 01/02/2025
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 JAMES RIVER TURNPIKE
MILTON WV
25541
US

IV. Provider business mailing address

PO BOX 369
RIPLEY WV
25271-0369
US

V. Phone/Fax

Practice location:
  • Phone: 304-563-3241
  • Fax:
Mailing address:
  • Phone: 304-786-7418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: