MEDICARE: STEPHANIE JUNE PENNYPACKER MS

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	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1568181428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE JUNE PENNYPACKER MS

Provider Business Mailing Address
First Line	:	2165 TUCKER ST APT 2318
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-0196
Country	:	US
Telephone Number	:	940-393-3728
Fax Number	:

Provider Business Practice Location Address
First Line	:	2165 TUCKER ST APT 2318
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-0196
Country	:	US
Telephone Number	:	940-393-3728
Fax Number	:

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

Provider Enumeration Date	:	08/24/2022
Last Update Date	:	08/24/2022

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