MEDICARE: IAN PENWELL CPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife

General Provider Information

NPI Number	:	1154657096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN PENWELL CPM

Provider Business Mailing Address
First Line	:	2829 N CITRUS PL
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-5185
Country	:	US
Telephone Number	:	208-585-8788
Fax Number	:	208-629-5614

Provider Business Practice Location Address
First Line	:	2829 N CITRUS PL
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-5185
Country	:	US
Telephone Number	:	208-585-8788
Fax Number	:	208-629-5614

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2009
Last Update Date	:	10/28/2009

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Directions to “ IAN PENWELL CPM” Practice Location

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