Provider Demographics
NPI:1861488546
Name:PENN, MARY CATHARINE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CATHARINE
Last Name:PENN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:400 COLONNADE DR
Practice Address - Street 2:SUITE 160
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081
Practice Address - Country:US
Practice Address - Phone:904-824-1020
Practice Address - Fax:904-824-5333
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2849942363LF0000X
FLAPRN2849942363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3050408-00Medicaid
FLE87687Medicare ID - Type Unspecified
FLP75738Medicare UPIN