Provider Demographics
NPI:1376589143
Name:PENNINGTON, DONNA S (NP)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:S
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 GULL RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1650
Mailing Address - Country:US
Mailing Address - Phone:269-488-2191
Mailing Address - Fax:269-488-2191
Practice Address - Street 1:1535 GULL RD
Practice Address - Street 2:# 150
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1650
Practice Address - Country:US
Practice Address - Phone:269-488-2191
Practice Address - Fax:269-488-2191
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704135201363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008704510OtherBCBS PIN
MI5008704510OtherBCBS PIN
MI0N83150002Medicare ID - Type Unspecified
MI5008704510OtherBCBS PIN