Provider Demographics
NPI:1144755984
Name:PENNYWELL, JOANNA
Entity Type:Individual
Prefix:MRS
First Name:JOANNA
Middle Name:
Last Name:PENNYWELL
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 1:24635 ETON AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125-1807
Mailing Address - Country:US
Mailing Address - Phone:313-401-6739
Mailing Address - Fax:
Practice Address - Street 1:2181 SHERATON DR
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-1944
Practice Address - Country:US
Practice Address - Phone:313-401-6739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704248741367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered