Provider Demographics
NPI:1922520501
Name:PENROD, HALEY (OD)
Entity Type:Individual
Prefix:DR
First Name:HALEY
Middle Name:
Last Name:PENROD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4056 IDLEVALE DR
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-7815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 UPPER RIVERDALE RD SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2540
Practice Address - Country:US
Practice Address - Phone:770-994-9913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3045152W00000X
GAOPT003045152WV0400X
AZ2428152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy