Provider Demographics
NPI:1912546649
Name:SHELDON, PENNY LEE
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:LEE
Last Name:SHELDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 COUNTY ROUTE 45
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-2226
Mailing Address - Country:US
Mailing Address - Phone:315-591-5490
Mailing Address - Fax:
Practice Address - Street 1:747 COUNTY ROUTE 45
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-2226
Practice Address - Country:US
Practice Address - Phone:315-591-5490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-28
Last Update Date:2019-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist