Provider Demographics
NPI:1518448307
Name:PENNO, MICHELLE RUTH (FNP-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RUTH
Last Name:PENNO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6677 W THUNDERBIRD RD STE C142
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3760
Mailing Address - Country:US
Mailing Address - Phone:480-963-1853
Mailing Address - Fax:602-973-0978
Practice Address - Street 1:13430 N SCOTTSDALE RD STE 200
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4058
Practice Address - Country:US
Practice Address - Phone:888-407-7928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily