Provider Demographics
NPI:1023486362
Name:SANDERS, PENNY NGUYEN
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:NGUYEN
Last Name:SANDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:NGUYEN
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 721745
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA
Mailing Address - State:OK
Mailing Address - Zip Code:73172
Mailing Address - Country:US
Mailing Address - Phone:405-204-8530
Mailing Address - Fax:
Practice Address - Street 1:5409 NW 119TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-1970
Practice Address - Country:US
Practice Address - Phone:405-204-8530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200712940BMedicaid