Provider Demographics
NPI:1326290818
Name:PENNAZ, AMY JO (DPT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:PENNAZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 UNIVERSITY AVE
Mailing Address - Street 2:STE 10A
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3828
Mailing Address - Country:US
Mailing Address - Phone:651-646-7246
Mailing Address - Fax:651-641-0726
Practice Address - Street 1:11 BRIDGE STREET PLAZA
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921
Practice Address - Country:US
Practice Address - Phone:410-392-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1326290818Medicaid
3579964000OtherIBC AMERIHEALTH
3579964000OtherIBC AMERIHEALTH
MD136761ZBL8Medicare PIN