Provider Demographics
NPI:1417458811
Name:PENNINGTON, TANNYA I (PTA)
Entity Type:Individual
Prefix:
First Name:TANNYA
Middle Name:I
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:LONOKE
Mailing Address - State:AR
Mailing Address - Zip Code:72086-0183
Mailing Address - Country:US
Mailing Address - Phone:501-425-9738
Mailing Address - Fax:501-676-3386
Practice Address - Street 1:154 CORNERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6560
Practice Address - Country:US
Practice Address - Phone:501-525-0575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1343225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140877721Medicaid