Provider Demographics
NPI:1558742197
Name:ALTMAN, PENNY (NP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:ALTMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 PROFESSIONAL BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-8018
Mailing Address - Country:US
Mailing Address - Phone:812-477-7246
Mailing Address - Fax:124-777-2408
Practice Address - Street 1:1101 PROFESSIONAL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-8018
Practice Address - Country:US
Practice Address - Phone:812-477-7246
Practice Address - Fax:124-777-2408
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020048363L00000X, 363L00000X
IN71005962B363LF0000X
IN28223959A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300034218Medicaid