Provider Demographics
NPI:1598123036
Name:PENNEY, SUSAN M (CNM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:PENNEY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 25317
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-5317
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:3438 LAWTON RD # 2B
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-2948
Practice Address - Country:US
Practice Address - Phone:407-422-1608
Practice Address - Fax:407-423-2672
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11001441363L00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102553000Medicaid
NH3103917Medicaid
NHT400299133Medicare PIN