Provider Demographics
NPI:1003903782
Name:FARRELL, PENNY LANE (DPT)
Entity Type:Individual
Prefix:DR
First Name:PENNY
Middle Name:LANE
Last Name:FARRELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:PENNYLANE
Other - Middle Name:
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:5949 W RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-4348
Mailing Address - Country:US
Mailing Address - Phone:317-390-5575
Mailing Address - Fax:317-486-2189
Practice Address - Street 1:5949 W RAYMOND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-4348
Practice Address - Country:US
Practice Address - Phone:317-390-5575
Practice Address - Fax:317-486-2189
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22939225100000X
IN05009423A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106593Medicare ID - Type UnspecifiedMEDICARE