Provider Demographics
NPI:1124202650
Name:LINNA, PENNIE J
Entity Type:Individual
Prefix:
First Name:PENNIE
Middle Name:J
Last Name:LINNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5920
Mailing Address - Country:US
Mailing Address - Phone:920-832-4741
Mailing Address - Fax:920-832-2185
Practice Address - Street 1:410 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5920
Practice Address - Country:US
Practice Address - Phone:920-832-4741
Practice Address - Fax:920-832-2185
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3124-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43574800Medicaid