Provider Demographics
NPI:1851590269
Name:PENROD, WARREN LARRY (FNP, BC)
Entity Type:Individual
Prefix:MR
First Name:WARREN
Middle Name:LARRY
Last Name:PENROD
Suffix:
Gender:M
Credentials:FNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W. WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601
Mailing Address - Country:US
Mailing Address - Phone:574-299-4847
Mailing Address - Fax:574-299-9073
Practice Address - Street 1:333 W. WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601
Practice Address - Country:US
Practice Address - Phone:574-299-4847
Practice Address - Fax:574-299-9073
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28135343A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily