Provider Demographics
NPI:1518128909
Name:PENNELL, KIRSTEN N (MD)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:N
Last Name:PENNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 7549
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0549
Mailing Address - Country:US
Mailing Address - Phone:757-686-3525
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:4092 FOXWOOD DR.
Practice Address - Street 2:STE 101
Practice Address - City:VA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5225
Practice Address - Country:US
Practice Address - Phone:757-467-4200
Practice Address - Fax:757-686-0541
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116018438390200000X
VA0101245787207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA020046E07Medicare PIN