Provider Demographics
NPI:1295038149
Name:PENNYWELL, THEA C (PA)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:C
Last Name:PENNYWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7925 YOUREE DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5127
Mailing Address - Country:US
Mailing Address - Phone:318-424-3400
Mailing Address - Fax:318-629-8712
Practice Address - Street 1:7925 YOUREE DR
Practice Address - Street 2:SUITE 220
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5127
Practice Address - Country:US
Practice Address - Phone:318-424-3400
Practice Address - Fax:318-629-8712
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAPA200405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant