=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598571093
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PENNY WILSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2024
-----------------------------------------------------
Last Update Date | 12/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1103 E MAIN ST STE C
-----------------------------------------------------
City | MOUNTAIN VIEW
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72560-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-683-2993
-----------------------------------------------------
Fax | 866-922-9146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1103 E MAIN ST STE C
-----------------------------------------------------
City | MOUNTAIN VIEW
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72560-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-683-2993
-----------------------------------------------------
Fax | 866-922-9146
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 123612
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------