Provider Demographics
NPI:1952838310
Name:PENNINGTON, TIMOTHY MARK (NP-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MARK
Last Name:PENNINGTON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PARKVIEW ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-2242
Mailing Address - Country:US
Mailing Address - Phone:1513-379-5697
Mailing Address - Fax:
Practice Address - Street 1:4222 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-6129
Practice Address - Country:US
Practice Address - Phone:513-420-4678
Practice Address - Fax:513-420-4678
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020820363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily