Provider Demographics
NPI:1629166855
Name:PENNING, KIERAN L (NP)
Entity Type:Individual
Prefix:
First Name:KIERAN
Middle Name:L
Last Name:PENNING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9660 WICKER AVENUE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ST JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9487
Mailing Address - Country:US
Mailing Address - Phone:219-226-2380
Mailing Address - Fax:219-226-2381
Practice Address - Street 1:9660 WICKER AVENUE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ST JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9487
Practice Address - Country:US
Practice Address - Phone:219-226-2380
Practice Address - Fax:219-226-2381
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001464A363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200932310Medicaid