Provider Demographics
NPI:1558393330
Name:DILLON, PENELOPE JANE (FNP-C ,PSYCH NP-C, C)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:JANE
Last Name:DILLON
Suffix:
Gender:F
Credentials:FNP-C ,PSYCH NP-C, C
Other - Prefix:
Other - First Name:PENELOPE
Other - Middle Name:JANE
Other - Last Name:DILLON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP CNS
Mailing Address - Street 1:26 QUEEN STREET
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2473
Mailing Address - Country:US
Mailing Address - Phone:508-860-7700
Mailing Address - Fax:508-860-7929
Practice Address - Street 1:26 QUEEN STREET
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2473
Practice Address - Country:US
Practice Address - Phone:508-860-7700
Practice Address - Fax:508-860-7929
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA122882363L00000X, 207Q00000X
MA122882 NP364SP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS92251Medicare UPIN