Provider Demographics
NPI:1669450508
Name:PENNER, TERRY LYNN (MS ANP-C ACNP-BC)
Entity Type:Individual
Prefix:MS
First Name:TERRY
Middle Name:LYNN
Last Name:PENNER
Suffix:
Gender:F
Credentials:MS ANP-C ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3514 N POWER RD STE 127
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-2911
Mailing Address - Country:US
Mailing Address - Phone:480-571-8460
Mailing Address - Fax:480-571-8461
Practice Address - Street 1:3514 N POWER RD STE 127
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-2911
Practice Address - Country:US
Practice Address - Phone:480-571-8460
Practice Address - Fax:480-571-8461
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-31
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP-1086363LA2100X, 363LA2200X
AZRN066900363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ584947Medicaid