Provider Demographics
NPI:1144243692
Name:PENNISTON, TIMOTHY R (FNP-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:PENNISTON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-1061
Mailing Address - Country:US
Mailing Address - Phone:520-281-1550
Mailing Address - Fax:520-281-2335
Practice Address - Street 1:2352 QUARTER HORSE TRL
Practice Address - Street 2:
Practice Address - City:OVERGAARD
Practice Address - State:AZ
Practice Address - Zip Code:85933-5319
Practice Address - Country:US
Practice Address - Phone:928-535-3616
Practice Address - Fax:928-532-2156
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ453927Medicaid
WY120656700Medicaid
WYW20201Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
WY313097OtherBLUE CROSS INDIVIDUAL NUM