Provider Demographics
NPI:1851832695
Name:REA, PENNY (NP-C)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:REA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5307 GREEN VALLEY PL
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5790
Mailing Address - Country:US
Mailing Address - Phone:208-899-7105
Mailing Address - Fax:
Practice Address - Street 1:5307 GREEN VALLEY PL
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5790
Practice Address - Country:US
Practice Address - Phone:208-899-7105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55370363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care