Provider Demographics
NPI:1376657452
Name:PENGELLY, MARTHA WEBSTER (LMP)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:WEBSTER
Last Name:PENGELLY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MS
Other - First Name:MARTHA
Other - Middle Name:WEBSTER
Other - Last Name:BINDER-PENGELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:8503 W CLEARWATER AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-3100
Mailing Address - Country:US
Mailing Address - Phone:509-374-4719
Mailing Address - Fax:509-374-3873
Practice Address - Street 1:8503 W CLEARWATER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3100
Practice Address - Country:US
Practice Address - Phone:509-374-4719
Practice Address - Fax:509-374-3873
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist