Provider Demographics
NPI:1003317108
Name:MOSHER, PENNY (MSW INTERN)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:MOSHER
Suffix:
Gender:F
Credentials:MSW INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6550
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-6550
Mailing Address - Country:US
Mailing Address - Phone:315-782-7445
Mailing Address - Fax:315-779-1184
Practice Address - Street 1:167 POLK ST STE 300
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2770
Practice Address - Country:US
Practice Address - Phone:315-782-7445
Practice Address - Fax:315-779-1184
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3372621Medicaid