Provider Demographics
NPI:1033401385
Name:PHIFER, PENNE SUE ELLEN (LMT)
Entity Type:Individual
Prefix:
First Name:PENNE
Middle Name:SUE ELLEN
Last Name:PHIFER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 SW 4TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-1322
Mailing Address - Country:US
Mailing Address - Phone:541-480-1643
Mailing Address - Fax:
Practice Address - Street 1:212 SW 4TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1322
Practice Address - Country:US
Practice Address - Phone:541-480-1643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16496172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist