Provider Demographics
NPI:1154319374
Name:PENNY-FORSYTH, MALISSA (NP)
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:
Last Name:PENNY-FORSYTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 848601
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8601
Mailing Address - Country:US
Mailing Address - Phone:303-295-8737
Mailing Address - Fax:303-298-1862
Practice Address - Street 1:1444 S POTOMAC ST
Practice Address - Street 2:SUITE 300
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80012-4508
Practice Address - Country:US
Practice Address - Phone:303-750-0822
Practice Address - Fax:303-750-1298
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO76958363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP47441Medicare UPIN
COC513828Medicare PIN