Provider Demographics
NPI:1487644290
Name:PENNINGTON TAYLOR, JENNIFER NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:PENNINGTON TAYLOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:PENNINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1500 TERRACE STREET
Mailing Address - Street 2:PO BOX 940
Mailing Address - City:HINTON
Mailing Address - State:WV
Mailing Address - Zip Code:25951
Mailing Address - Country:US
Mailing Address - Phone:304-466-2905
Mailing Address - Fax:304-466-2917
Practice Address - Street 1:1500 TERRACE STREET
Practice Address - Street 2:
Practice Address - City:HINTON
Practice Address - State:WV
Practice Address - Zip Code:25951
Practice Address - Country:US
Practice Address - Phone:304-466-2905
Practice Address - Fax:304-466-2917
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01014363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001365Medicaid
WV520795528OtherAETNA
WVP97100Medicare UPIN
WV3810001365Medicaid