Provider Demographics
NPI:1093710733
Name:PENNELLE, DONALD KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:KENNETH
Last Name:PENNELLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SHADOW LN
Mailing Address - Street 2:STE 470
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4159
Mailing Address - Country:US
Mailing Address - Phone:702-383-9800
Mailing Address - Fax:702-383-9841
Practice Address - Street 1:700 SHADOW LN
Practice Address - Street 2:STE 470
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4159
Practice Address - Country:US
Practice Address - Phone:702-383-9800
Practice Address - Fax:702-383-9841
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3969207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C96430Medicare UPIN