Provider Demographics
NPI:1083664478
Name:PENN, STEVEN L (CRNA)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:L
Last Name:PENN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15540 PROMENADE AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1123
Mailing Address - Country:US
Mailing Address - Phone:313-388-5837
Mailing Address - Fax:
Practice Address - Street 1:22401 FOSTER WINTER DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3724
Practice Address - Country:US
Practice Address - Phone:248-423-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704138637367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered