MEDICARE: TYBRIA PENNY

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	171M00000X	Case Manager/Care Coordinator
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1730922758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYBRIA PENNY

Provider Business Mailing Address
First Line	:	3625 FULL MOON AVE APT 2435
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-6928
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3625 FULL MOON AVENUE, UNIT 2435
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262
Country	:	US
Telephone Number	:	910-431-6063
Fax Number	:

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

Provider Enumeration Date	:	06/17/2024
Last Update Date	:	08/08/2025

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Directions to “ TYBRIA PENNY ” Practice Location

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