Provider Demographics
NPI:1518247758
Name:MADER, PENNY J (CNP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:J
Last Name:MADER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4232
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:ATTN CREDENTIALING
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-354-8225
Practice Address - Fax:801-418-0941
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13327156-4405363L00000X
NMCNP-01828363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM48922218Medicaid
NMNMAAA1913Medicare UPIN