Provider Demographics
NPI:1609490523
Name:BALLESTER, PENNY-LANE XANADU
Entity Type:Individual
Prefix:
First Name:PENNY-LANE
Middle Name:XANADU
Last Name:BALLESTER
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 1:21352 SW 112TH AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-2969
Mailing Address - Country:US
Mailing Address - Phone:305-458-6868
Mailing Address - Fax:
Practice Address - Street 1:21352 SW 112TH AVE APT 205
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-2969
Practice Address - Country:US
Practice Address - Phone:305-458-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician