MEDICARE: MRS. HOLLY PENNINGTON MPT

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	225100000X	Physical Therapist	PT00008860	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346232022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HOLLY PENNINGTON MPT

Provider Business Mailing Address
First Line	:	26837 MAPLE VALLEY BLACK DIAMOND RD SE
Second Line	:	STE 200
City	:	MAPLE VALLEY
State	:	WA
Zip	:	98038-9917
Country	:	US
Telephone Number	:	425-413-4427
Fax Number	:	425-413-4402

Provider Business Practice Location Address
First Line	:	8910 184TH AVE E
Second Line	:
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-8531
Country	:	US
Telephone Number	:	253-863-7510
Fax Number	:	253-863-5970

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	11/22/2016

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