Provider Demographics
NPI:1942075650
Name:PENNER, DEVON (DC)
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:PENNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 W BRENTON ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644
Mailing Address - Country:US
Mailing Address - Phone:986-837-7884
Mailing Address - Fax:
Practice Address - Street 1:108 E PINE ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4836
Practice Address - Country:US
Practice Address - Phone:208-459-0858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACP-467171100000X
IDCHIA-2324111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist