Provider Demographics
NPI:1558091157
Name:PENICK, KATHLYN LARA (PA)
Entity Type:Individual
Prefix:
First Name:KATHLYN
Middle Name:LARA
Last Name:PENICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 INTEGRA VILLAGE TRL APT 3-315
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-9289
Mailing Address - Country:US
Mailing Address - Phone:727-389-9253
Mailing Address - Fax:
Practice Address - Street 1:2776 ENTERPRISE RD STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8316
Practice Address - Country:US
Practice Address - Phone:386-774-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9116046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant