Provider Demographics
NPI:1760824783
Name:WOODWARD, PENELOPE (OTR)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:
Last Name:WOODWARD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4906
Mailing Address - Country:US
Mailing Address - Phone:719-207-0994
Mailing Address - Fax:719-276-6199
Practice Address - Street 1:490 N DIAMOND AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2521
Practice Address - Country:US
Practice Address - Phone:719-276-6174
Practice Address - Fax:719-276-6199
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0031319171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95138340Medicaid