Provider Demographics
NPI:1831109602
Name:PENNA, SHELLEY (NP)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:PENNA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1961
Mailing Address - Country:US
Mailing Address - Phone:781-779-4878
Mailing Address - Fax:
Practice Address - Street 1:1 PARK WAY
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-6278
Practice Address - Country:US
Practice Address - Phone:978-521-3270
Practice Address - Fax:978-469-5320
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA264644363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP5445OtherBLUE CROSS BLUE SHIELD
MAQ72309Medicare UPIN
MANP5445Medicare PIN