Provider Demographics
NPI:1407488158
Name:PENNER, NICOLE RAE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:PENNER
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 1:5652 JELLISON ST
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-2145
Mailing Address - Country:US
Mailing Address - Phone:218-686-4965
Mailing Address - Fax:
Practice Address - Street 1:5652 JELLISON ST
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80002-2145
Practice Address - Country:US
Practice Address - Phone:218-686-4965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health