Provider Demographics
NPI:1053072421
Name:PENNYCOOKE, HEREWARD
Entity Type:Individual
Prefix:
First Name:HEREWARD
Middle Name:
Last Name:PENNYCOOKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3489 NW 24TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33311-2610
Mailing Address - Country:US
Mailing Address - Phone:954-822-3092
Mailing Address - Fax:
Practice Address - Street 1:3489 NW 24TH ST
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33311-2610
Practice Address - Country:US
Practice Address - Phone:954-822-3092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL117549003747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3747A0650XMedicaid