Provider Demographics
NPI:1417729583
Name:PENNEKAMP, DECEMBER (FNP-BC)
Entity Type:Individual
Prefix:
First Name:DECEMBER
Middle Name:
Last Name:PENNEKAMP
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5765 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5166
Mailing Address - Country:US
Mailing Address - Phone:513-490-2365
Mailing Address - Fax:
Practice Address - Street 1:4130 DRY RIDGE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45252-1914
Practice Address - Country:US
Practice Address - Phone:513-490-2365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0035176363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily