Provider Demographics
NPI:1568834935
Name:PENN, BETSY
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:
Last Name:PENN
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 1:16658 COTHERMAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-9749
Mailing Address - Country:US
Mailing Address - Phone:269-251-2777
Mailing Address - Fax:
Practice Address - Street 1:16658 COTHERMAN LAKE RD
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-9749
Practice Address - Country:US
Practice Address - Phone:269-251-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2333988251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health