Provider Demographics
NPI:1528046208
Name:MCDONNELL-PENROSE, NANCY THERESA (PT)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:THERESA
Last Name:MCDONNELL-PENROSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:NANCY
Other - Middle Name:THERESA
Other - Last Name:MCDONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 2182
Mailing Address - Street 2:180 W 1ST ST #101
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-2182
Mailing Address - Country:US
Mailing Address - Phone:208-725-5185
Mailing Address - Fax:208-725-5192
Practice Address - Street 1:180 W 1ST ST #101
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-725-5185
Practice Address - Fax:208-725-5192
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDTS832OtherBLUE CROSS
ID1653500Medicare ID - Type Unspecified