Provider Demographics
NPI:1023291127
Name:FEVERGEON, PENNY LEW (MS, RD)
Entity type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:LEW
Last Name:FEVERGEON
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1533 VIA FERNANDEZ
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-1944
Mailing Address - Country:US
Mailing Address - Phone:310-371-0813
Mailing Address - Fax:310-371-6851
Practice Address - Street 1:1533 VIA FERNANDEZ
Practice Address - Street 2:
Practice Address - City:PALOS VERDES ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-1944
Practice Address - Country:US
Practice Address - Phone:310-371-0813
Practice Address - Fax:310-371-6851
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA418881133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered