Provider Demographics
NPI:1003684853
Name:PENNELL, LAVINA J
Entity Type:Individual
Prefix:
First Name:LAVINA
Middle Name:J
Last Name:PENNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-2066
Mailing Address - Country:US
Mailing Address - Phone:618-501-2462
Mailing Address - Fax:
Practice Address - Street 1:50 OHIO ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-2066
Practice Address - Country:US
Practice Address - Phone:618-501-2462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821206228Medicaid
WV125553494Medicaid
WV1356607394Medicaid