Provider Demographics
NPI:1821149634
Name:PENNEY, LYNN MARIE (NPP)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:MARIE
Last Name:PENNEY
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WILDWOOD LA
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3487
Mailing Address - Country:US
Mailing Address - Phone:631-656-8993
Mailing Address - Fax:
Practice Address - Street 1:269 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3487
Practice Address - Country:US
Practice Address - Phone:631-335-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3715241163W00000X
NYF4007251363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02553588Medicaid