Provider Demographics
NPI:1255869335
Name:PENNINGTON-PEACE, ANDREA NICOLE (CSA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:PENNINGTON-PEACE
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 SANDY WAY
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-6550
Mailing Address - Country:US
Mailing Address - Phone:214-704-5474
Mailing Address - Fax:
Practice Address - Street 1:1935 MEDIAL DISTRICT
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235
Practice Address - Country:US
Practice Address - Phone:214-456-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4694246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty