Provider Demographics
NPI:1285186288
Name:PENKACIK, HOLLY (APRN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:PENKACIK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CELLINI PL STE 102
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-1666
Mailing Address - Country:US
Mailing Address - Phone:203-932-6481
Mailing Address - Fax:
Practice Address - Street 1:1 CELLINI PL STE 102
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-1666
Practice Address - Country:US
Practice Address - Phone:203-932-6481
Practice Address - Fax:203-932-4051
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.006797363LG0600X
CT6797363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology