Provider Demographics
NPI:1720377740
Name:PENNINGTON, PHYLLIS A (DO)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:A
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-2205
Mailing Address - Country:US
Mailing Address - Phone:719-486-1264
Mailing Address - Fax:719-486-1286
Practice Address - Street 1:1338 PHAY AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2311
Practice Address - Country:US
Practice Address - Phone:719-285-2700
Practice Address - Fax:719-285-2975
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0052834207R00000X
CO0052834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine