Provider Demographics
NPI:1598091910
Name:PENWELL, VICKI ALLEN (CPM)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:ALLEN
Last Name:PENWELL
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190563
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0563
Mailing Address - Country:US
Mailing Address - Phone:208-954-6788
Mailing Address - Fax:
Practice Address - Street 1:2829 N CITRUS PL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5185
Practice Address - Country:US
Practice Address - Phone:208-954-6788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM83069-R176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife