Provider Demographics
NPI:1033200183
Name:ATTAWAY, PENNY (DNP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:ATTAWAY
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 N 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471
Mailing Address - Country:US
Mailing Address - Phone:618-283-2000
Mailing Address - Fax:618-283-2002
Practice Address - Street 1:1404 N 5TH STREET
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471
Practice Address - Country:US
Practice Address - Phone:618-283-2000
Practice Address - Fax:618-283-2002
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001693363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
L040233OtherTRICARE INS
IL371352296003Medicaid
IL371352296003Medicaid
IL783833Medicare PIN
L040233OtherTRICARE INS
IL148945Medicare Oscar/Certification
P60599Medicare UPIN
IL371352296004Medicaid