MEDICARE: MS. MARY CATHARINE PENN ARNP

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	363LF0000X	Family Nurse Practitioner	2849942	FL
2	363L00000X	Nurse Practitioner	APRN2849942	FL

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	:	1861488546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY CATHARINE PENN ARNP

Provider Business Mailing Address
First Line	:	PO BOX 45443
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84145-0443
Country	:	US
Telephone Number	:	904-202-1032
Fax Number	:	904-376-4107

Provider Business Practice Location Address
First Line	:	400 COLONNADE DR
Second Line	:	SUITE 160
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081
Country	:	US
Telephone Number	:	904-824-1020
Fax Number	:	904-824-5333

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

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	02/13/2021

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