Provider Demographics
NPI:1497147615
Name:ROUSSIN, PENNIE
Entity Type:Individual
Prefix:
First Name:PENNIE
Middle Name:
Last Name:ROUSSIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 STATE HIGHWAY 150 S
Mailing Address - Street 2:SUITE J
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1575 STATE HIGHWAY 150 S
Practice Address - Street 2:SUITE J
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5349
Practice Address - Country:US
Practice Address - Phone:307-789-7915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker