Provider Demographics
NPI:1144665258
Name:ANDERSON, PENNY H (LMT, MMP)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:H
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6224 S LOBELIA DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-4001
Mailing Address - Country:US
Mailing Address - Phone:801-688-5248
Mailing Address - Fax:
Practice Address - Street 1:881 S OREM BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5033
Practice Address - Country:US
Practice Address - Phone:801-688-5248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5323962-4701172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist