Provider Demographics
NPI:1710944863
Name:CREMER, PENNI LORRAINE (PMHCNS-BC)
Entity Type:Individual
Prefix:MRS
First Name:PENNI
Middle Name:LORRAINE
Last Name:CREMER
Suffix:
Gender:F
Credentials:PMHCNS-BC
Other - Prefix:
Other - First Name:PENNI
Other - Middle Name:LORRAINE
Other - Last Name:FUQUA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHCNS-BC
Mailing Address - Street 1:12539 PEBBLEPOINTE PASS
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033
Mailing Address - Country:US
Mailing Address - Phone:317-709-3365
Mailing Address - Fax:
Practice Address - Street 1:1424 E 91ST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1902
Practice Address - Country:US
Practice Address - Phone:317-709-3365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000131A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200405980Medicaid
IN215620AMedicare PIN
IN200405980Medicaid