Provider Demographics
NPI:1114228079
Name:PENWELL MINCHER, NICOLE (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:PENWELL MINCHER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:PENWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPTA
Mailing Address - Street 1:6707 LAKE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-2839
Mailing Address - Country:US
Mailing Address - Phone:804-824-8471
Mailing Address - Fax:
Practice Address - Street 1:6707 LAKE VIEW DR
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-2839
Practice Address - Country:US
Practice Address - Phone:804-824-8471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602972225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant