Provider Demographics
NPI:1437239688
Name:PENNY, VICKI (NP)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:PENNY
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 1:1360 W 6TH ST
Mailing Address - Street 2:SUITE 125, NORTH BUILDING
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3514
Mailing Address - Country:US
Mailing Address - Phone:310-831-8952
Mailing Address - Fax:310-831-0568
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:SUITE 125, NORTH BUILDING
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-831-8952
Practice Address - Fax:310-831-0568
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8085363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner