Provider Demographics
NPI:1205325966
Name:PENATE, GLORIA JUDITH I
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:JUDITH
Last Name:PENATE
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MADIGAN ANNEX 9900
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-4944
Mailing Address - Fax:253-968-4900
Practice Address - Street 1:2103 NORTH DIVISION STREET
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:253-967-3416
Practice Address - Fax:253-966-7848
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22724124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22724OtherDEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE