Provider Demographics
NPI:1093139727
Name:PENISTEN, JENNIFER (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:PENISTEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 86TH ST
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-4201
Mailing Address - Country:US
Mailing Address - Phone:515-276-3406
Mailing Address - Fax:
Practice Address - Street 1:2901 86TH ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-4201
Practice Address - Country:US
Practice Address - Phone:515-276-3406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-17
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA114664363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1093139727Medicaid
IAP01353220OtherRR MEDICARE
IA719260631Medicare UPIN