Provider Demographics
NPI:1689985764
Name:PENN, JAMES LEE (PTA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LEE
Last Name:PENN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 RICHARDSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-3473
Mailing Address - Country:US
Mailing Address - Phone:260-399-4880
Mailing Address - Fax:
Practice Address - Street 1:5700 WILKIE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1662
Practice Address - Country:US
Practice Address - Phone:260-432-7556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003741A225200000X
TX2076106225200000X
TN4793225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant