Provider Demographics
NPI:1689213621
Name:PATTERSON, PENNY MAE
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:MAE
Last Name:PATTERSON
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 1:416 WAYMARKET DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6435
Mailing Address - Country:US
Mailing Address - Phone:734-548-5812
Mailing Address - Fax:
Practice Address - Street 1:3200 E EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-3231
Practice Address - Country:US
Practice Address - Phone:734-660-2819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-21
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI4704371853163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician