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General NPI Number Information
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NPI Number | 1184741175
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Entity Type | Organization
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Legal Business Name | PENNY ATTAWAY
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Dates
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Enumeration Date | 03/23/2007
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Last Update Date | 01/19/2009
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Provider Practice Location Address
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Address Line | 1411 W MAIN ST WESTPORT PLAZA
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City | FAIRFIELD
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State | IL
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Zip | 62837-2300
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Country | US
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Telephone | 618-842-5285
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Fax | 618-842-4576
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Provider Business Mailing Address
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Address Line | 1411 W MAIN ST WESTPORT PLAZA
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City | FAIRFIELD
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State | IL
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Zip | 62837-2300
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Country | US
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Telephone | 618-842-5285
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Fax | 618-842-4576
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Authorized Official
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Title or Position | OWNER, FNP
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Name | PENNY ATTAWAY
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Credential | MSN FNP
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Telephone | 618-842-5285
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 209001693
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License Number State | IL
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