Provider Demographics
NPI:1609223478
Name:PENGRA, ANNA (MAT, LAT)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:PENGRA
Suffix:
Gender:F
Credentials:MAT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10402 NE 88TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-2178
Mailing Address - Country:US
Mailing Address - Phone:806-518-2014
Mailing Address - Fax:
Practice Address - Street 1:10402 NE 88TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-2178
Practice Address - Country:US
Practice Address - Phone:806-518-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT56512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer