Provider Demographics
NPI:1821297938
Name:PENNYCOOKE, SHELLEY ANN NICOLE
Entity Type:Individual
Prefix:
First Name:SHELLEY ANN
Middle Name:NICOLE
Last Name:PENNYCOOKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELLEY ANN
Other - Middle Name:NICOLE
Other - Last Name:MURRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:18 E LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 E LAUREL RD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1327
Practice Address - Country:US
Practice Address - Phone:856-346-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPRACTICING207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00766006OtherRR MEDICARE
NJ0181943Medicaid
NJ140511SN3Medicare PIN
NJ0181943Medicaid