Provider Demographics
NPI:1780224238
Name:VANWEORT, PENELOPE EVON (PT)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:EVON
Last Name:VANWEORT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 US OVAL
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12903-3913
Mailing Address - Country:US
Mailing Address - Phone:585-760-5271
Mailing Address - Fax:
Practice Address - Street 1:176 US OVAL
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12903-3913
Practice Address - Country:US
Practice Address - Phone:585-760-5271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008525-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist