MEDICARE: MS. TERRY LYNN PENNER MS ANP-C ACNP-BC

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	363LA2100X	Acute Care Nurse Practitioner	AP-1086	AZ
2	363LA2200X	Adult Health Nurse Practitioner	RN066900	AZ
3	363LA2200X	Adult Health Nurse Practitioner	AP-1086	AZ

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	:	1669450508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TERRY LYNN PENNER MS ANP-C ACNP-BC

Provider Business Mailing Address
First Line	:	3514 N POWER RD STE 127
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85215-2911
Country	:	US
Telephone Number	:	480-571-8460
Fax Number	:	480-571-8461

Provider Business Practice Location Address
First Line	:	3514 N POWER RD STE 127
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85215-2911
Country	:	US
Telephone Number	:	480-571-8460
Fax Number	:	480-571-8461

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

Provider Enumeration Date	:	12/31/2005
Last Update Date	:	04/13/2019

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