Provider Demographics
NPI:1205066503
Name:ALI-PENNOCK, VANESSA AMBEREEN (DO)
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:AMBEREEN
Last Name:ALI-PENNOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 SUNNYSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-1517
Mailing Address - Country:US
Mailing Address - Phone:516-506-7776
Mailing Address - Fax:516-719-0708
Practice Address - Street 1:54 SUNNYSIDE BLVD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-1517
Practice Address - Country:US
Practice Address - Phone:516-506-7776
Practice Address - Fax:516-719-0708
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY260126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3545622Medicaid
NY3545622Medicaid