Provider Demographics
NPI:1861647794
Name:COSNER, PENNY L (LMT)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:L
Last Name:COSNER
Suffix:
Gender:F
Credentials:LMT
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 1573
Mailing Address - Street 2:
Mailing Address - City:ROGUE RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97537-1573
Mailing Address - Country:US
Mailing Address - Phone:541-582-3522
Mailing Address - Fax:541-582-4556
Practice Address - Street 1:112 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ROGUE RIVER
Practice Address - State:OR
Practice Address - Zip Code:97537-9419
Practice Address - Country:US
Practice Address - Phone:541-582-3522
Practice Address - Fax:541-582-4556
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9633174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist