Provider Demographics
NPI:1790336576
Name:PENNYWELL, JAVIER MONIQUE (BACHELOR OF ARTS)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:MONIQUE
Last Name:PENNYWELL
Suffix:
Gender:F
Credentials:BACHELOR OF ARTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 STONE ST
Mailing Address - Street 2:
Mailing Address - City:EUNICE
Mailing Address - State:LA
Mailing Address - Zip Code:70535-2871
Mailing Address - Country:US
Mailing Address - Phone:337-466-6965
Mailing Address - Fax:
Practice Address - Street 1:805 S UNION ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6029
Practice Address - Country:US
Practice Address - Phone:337-648-4004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator