Provider Demographics
NPI:1154685444
Name:PARKER, PENNY
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:PARKER
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 1:4234 9TH AVENUE CIR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2090
Mailing Address - Country:US
Mailing Address - Phone:701-429-4874
Mailing Address - Fax:
Practice Address - Street 1:4234 9TH AVENUE CIR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2090
Practice Address - Country:US
Practice Address - Phone:701-429-4874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X, 3747A0650X, 3747P1801X, 374U00000X
ND1524-586-731376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide