Provider Demographics
NPI:1164703765
Name:PENNER, KEVIN MARK (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MARK
Last Name:PENNER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 DRUMLIN CT
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1863
Mailing Address - Country:US
Mailing Address - Phone:131-554-8663
Mailing Address - Fax:
Practice Address - Street 1:131 DRUMLIN CT
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1863
Practice Address - Country:US
Practice Address - Phone:131-554-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008617-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist