MEDICARE: KRISTEN MICHELE PENNINGTON OT

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	225X00000X	Occupational Therapist	OT8106	FL

General Provider Information

NPI Number	:	1184876088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN MICHELE PENNINGTON OT

Provider Business Mailing Address
First Line	:	405 SAVANNAH PARK WAY
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32407-3273
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 SAVANNAH PARK WAY
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32407-3273
Country	:	US
Telephone Number	:	805-123-4567
Fax Number	:

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

Provider Enumeration Date	:	10/22/2008
Last Update Date	:	10/22/2008

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