Provider Demographics
NPI:1174287510
Name:WOLLENBERG PENNY, JAMIE LOUISE (DPT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LOUISE
Last Name:WOLLENBERG PENNY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LOUISE
Other - Last Name:WOLLENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:8320 WILLOW BEACH DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4113
Mailing Address - Country:US
Mailing Address - Phone:406-461-8100
Mailing Address - Fax:
Practice Address - Street 1:8320 WILLOW BEACH DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-4113
Practice Address - Country:US
Practice Address - Phone:406-461-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL37599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist