Provider Demographics
NPI:1346460284
Name:PENN, MARY J (RPT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:PENN
Suffix:
Gender:F
Credentials:RPT
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Mailing Address - Street 1:11523 S MULBERRY CT
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3462
Mailing Address - Country:US
Mailing Address - Phone:918-299-2542
Mailing Address - Fax:918-481-2976
Practice Address - Street 1:6585 S YALE AVE STE 445
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-9703
Practice Address - Country:US
Practice Address - Phone:918-481-2977
Practice Address - Fax:918-481-2976
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK2644225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist