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General NPI Number Information
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NPI Number | 1598247983
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Entity Type | Individual
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Provider Name | LACY PENWELL PTA
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Gender | Female
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Dates
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Enumeration Date | 08/31/2018
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Last Update Date | 08/31/2018
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Provider Practice Location Address
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Address Line | 1675 NE LOOP 286
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City | PARIS
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State | TX
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Zip | 75460-2219
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Country | US
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Telephone | 903-782-9922
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Fax |
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Provider Business Mailing Address
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Address Line | 303 COUNTY ROAD 44750
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City | BLOSSOM
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State | TX
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Zip | 75416-3916
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Country | US
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Telephone | 903-905-0499
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2136091
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License Number State | TX
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