Provider Demographics
NPI:1922348622
Name:PENNINGTON, ANGELA W (APRN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:W
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5200 COMMERCE CROSSINGS DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:525 TUCKER DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9182
Practice Address - Country:US
Practice Address - Phone:606-759-9921
Practice Address - Fax:606-759-9831
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY1091574163W00000X
KY3008028363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3008028OtherSTATE LICENSE
KY7100239710Medicaid
KY0169Medicare PIN
KY7100239710Medicaid