Provider Demographics
NPI:1275185993
Name:PENGELLEY, IVANNA REBECCA
Entity Type:Individual
Prefix:
First Name:IVANNA
Middle Name:REBECCA
Last Name:PENGELLEY
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 1:2110 S GADSDEN ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-5513
Mailing Address - Country:US
Mailing Address - Phone:561-309-9746
Mailing Address - Fax:
Practice Address - Street 1:2110 S GADSDEN ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-5513
Practice Address - Country:US
Practice Address - Phone:561-309-9746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist