Provider Demographics
NPI:1467402651
Name:IVERSON-AMMERAAL, PENNY SUE (OD)
Entity Type:Individual
Prefix:DR
First Name:PENNY
Middle Name:SUE
Last Name:IVERSON-AMMERAAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 ZEIER RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-7415
Mailing Address - Country:US
Mailing Address - Phone:608-244-4325
Mailing Address - Fax:
Practice Address - Street 1:2602 SHOPKO DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4074
Practice Address - Country:US
Practice Address - Phone:608-249-6967
Practice Address - Fax:608-249-7245
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2722152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38607700Medicaid
WI38607700Medicaid