Provider Demographics
NPI:1558796375
Name:GORE, PENNY ELAINE (RN)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:ELAINE
Last Name:GORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 PRESIDENTIAL DR
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76031-0303
Mailing Address - Country:US
Mailing Address - Phone:682-472-6651
Mailing Address - Fax:
Practice Address - Street 1:1101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4802
Practice Address - Country:US
Practice Address - Phone:817-321-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX555439261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local