Provider Demographics
NPI:1558482976
Name:PENNER, KANDACE ANN (MA, EDS, CCC-SP)
Entity Type:Individual
Prefix:MS
First Name:KANDACE
Middle Name:ANN
Last Name:PENNER
Suffix:
Gender:F
Credentials:MA, EDS, CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 NW 46TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4562
Mailing Address - Country:US
Mailing Address - Phone:352-373-7061
Mailing Address - Fax:
Practice Address - Street 1:1501 NW 46TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4562
Practice Address - Country:US
Practice Address - Phone:352-373-7061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA1407235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist