Provider Demographics
NPI:1558677815
Name:GAGNON, PENNY
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:GAGNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 KNIGHTS POND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03908-1933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 DEPOT RD
Practice Address - Street 2:
Practice Address - City:ELIOT
Practice Address - State:ME
Practice Address - Zip Code:03903-1278
Practice Address - Country:US
Practice Address - Phone:207-439-9197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist