MEDICARE: MS. KESI JEMILA GITTENS-PENNY PA-C

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	363A00000X	Physician Assistant	25MP00702800	NJ

General Provider Information

NPI Number	:	1932845260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KESI JEMILA GITTENS-PENNY PA-C

Provider Business Mailing Address
First Line	:	409 HILLSIDE AVE
Second Line	:
City	:	ORANGE
State	:	NJ
Zip	:	07050-2117
Country	:	US
Telephone Number	:	862-704-8553
Fax Number	:

Provider Business Practice Location Address
First Line	:	409 HILLSIDE AVE
Second Line	:
City	:	ORANGE
State	:	NJ
Zip	:	07050-2117
Country	:	US
Telephone Number	:	862-704-8553
Fax Number	:

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

Provider Enumeration Date	:	05/10/2022
Last Update Date	:	05/10/2022

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