Provider Demographics
NPI:1851759419
Name:PENN, LATONIA FAYE (LPTA)
Entity Type:Individual
Prefix:MS
First Name:LATONIA
Middle Name:FAYE
Last Name:PENN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PARK WEST CIR
Mailing Address - Street 2:108
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-5551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 PARK WEST CIR
Practice Address - Street 2:108
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-5551
Practice Address - Country:US
Practice Address - Phone:804-379-9265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601179225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty