Provider Demographics
NPI:1891936365
Name:YOUNG, PENNY B (APRN)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:B
Last Name:YOUNG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 SAYBROOK RD BLDG B
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4739
Mailing Address - Country:US
Mailing Address - Phone:860-347-2776
Mailing Address - Fax:
Practice Address - Street 1:770 SAYBROOK RD BLDG B
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4739
Practice Address - Country:US
Practice Address - Phone:860-347-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-13
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004015363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040150Medicaid
CTD400002506 -C00023Medicare PIN
CT004040150Medicaid