Provider Demographics
NPI:1518993799
Name:PENNINGTON, KIMBERLY M (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15195 HEATHCOTE BLVD
Mailing Address - Street 2:STE 330
Mailing Address - City:HAYMARKET
Mailing Address - State:VA
Mailing Address - Zip Code:20169-6242
Mailing Address - Country:US
Mailing Address - Phone:571-248-0167
Mailing Address - Fax:571-248-0173
Practice Address - Street 1:15195 HEATHCOTE BLVD
Practice Address - Street 2:STE 330
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-6242
Practice Address - Country:US
Practice Address - Phone:571-248-0167
Practice Address - Fax:571-248-0173
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110001585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q79377Medicare UPIN
VA000610E54Medicare ID - Type Unspecified