Provider Demographics
NPI:1306400262
Name:MOEN, PENNY ANN
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:ANN
Last Name:MOEN
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 1:20 PRESTON DR
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-3017
Mailing Address - Country:US
Mailing Address - Phone:608-778-2491
Mailing Address - Fax:
Practice Address - Street 1:20 PRESTON DR
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-3017
Practice Address - Country:US
Practice Address - Phone:608-778-2491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI236128163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse