Provider Demographics
NPI:1720574361
Name:PENTON, ALLYSON MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:MARIE
Last Name:PENTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 E LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:CARRIERE
Mailing Address - State:MS
Mailing Address - Zip Code:39426-7716
Mailing Address - Country:US
Mailing Address - Phone:601-622-2423
Mailing Address - Fax:
Practice Address - Street 1:1160 E LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:CARRIERE
Practice Address - State:MS
Practice Address - Zip Code:39426-7716
Practice Address - Country:US
Practice Address - Phone:601-622-2423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS885758363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00537363Medicaid