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General NPI Number Information
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NPI Number | 1891842464
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Entity Type | Individual
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Provider Name | SUSAN M PENNER OD
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Gender | Female
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Dates
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Enumeration Date | 01/04/2007
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Last Update Date | 06/18/2018
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Provider Practice Location Address
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Address Line | 134 E BLACKHAWK DR
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City | BYRON
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State | IL
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Zip | 61010
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Country | US
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Telephone | 815-234-2020
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Fax | 815-234-7070
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Provider Business Mailing Address
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Address Line | 134 E BLACKHAWK DR
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City | BYRON
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State | IL
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Zip | 61010-8610
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Country | US
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Telephone | 815-234-2020
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Fax | 815-234-7070
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046-008009
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License Number State | IL
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