Provider Demographics
NPI:1154657096
Name:PENWELL, IAN (CPM)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:PENWELL
Suffix:
Gender:M
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 N CITRUS PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5185
Mailing Address - Country:US
Mailing Address - Phone:208-585-8788
Mailing Address - Fax:208-629-5614
Practice Address - Street 1:2829 N CITRUS PL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5185
Practice Address - Country:US
Practice Address - Phone:208-585-8788
Practice Address - Fax:208-629-5614
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife