Provider Demographics
NPI:1346232022
Name:PENNINGTON, HOLLY (MPT)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MISS
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:26837 MAPLE VALLEY BLACK DIAMOND RD SE
Mailing Address - Street 2:STE 200
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-9917
Mailing Address - Country:US
Mailing Address - Phone:425-413-4427
Mailing Address - Fax:425-413-4402
Practice Address - Street 1:8910 184TH AVE E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8531
Practice Address - Country:US
Practice Address - Phone:253-863-7510
Practice Address - Fax:253-863-5970
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008860225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8333379Medicaid
WAAB32495Medicare ID - Type Unspecified
WA8333379Medicaid