Provider Demographics
NPI:1790555761
Name:PENNINGTON, JETTA NICOLE
Entity Type:Individual
Prefix:
First Name:JETTA NICOLE
Middle Name:
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 CHAMPION HILL PL
Mailing Address - Street 2:
Mailing Address - City:FISHERVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40023-8801
Mailing Address - Country:US
Mailing Address - Phone:606-831-1553
Mailing Address - Fax:
Practice Address - Street 1:2303 CHAMPION HILL PL
Practice Address - Street 2:
Practice Address - City:FISHERVILLE
Practice Address - State:KY
Practice Address - Zip Code:40023-8801
Practice Address - Country:US
Practice Address - Phone:606-831-1553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4014463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily