Provider Demographics
NPI:1346698941
Name:WALLMAN, PENNY SUE
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:SUE
Last Name:WALLMAN
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 1:677 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032-8524
Mailing Address - Country:US
Mailing Address - Phone:269-467-1000
Mailing Address - Fax:
Practice Address - Street 1:735 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:BRONSON
Practice Address - State:MI
Practice Address - Zip Code:49028-1349
Practice Address - Country:US
Practice Address - Phone:517-858-1400
Practice Address - Fax:517-858-1403
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704167228163W00000X, 363LP2300X
IN28167664A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse