Provider Demographics
NPI:1225784499
Name:PENNER, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:PENNER
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 1:208 PIERCE AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-3151
Mailing Address - Country:US
Mailing Address - Phone:734-788-2897
Mailing Address - Fax:
Practice Address - Street 1:2070 US HIGHWAY 1 STE 103
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3745
Practice Address - Country:US
Practice Address - Phone:321-632-0552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-26
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant