Provider Demographics
NPI:1245283795
Name:CROM, PENNY SUE (FNP)
Entity type:Individual
Prefix:MS
First Name:PENNY
Middle Name:SUE
Last Name:CROM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 WINGATE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81503-9529
Mailing Address - Country:US
Mailing Address - Phone:970-245-5731
Mailing Address - Fax:
Practice Address - Street 1:DEPT #0861
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80256-0001
Practice Address - Country:US
Practice Address - Phone:186-689-8713
Practice Address - Fax:616-975-9824
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO119700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO28989856Medicaid
CO930063846OtherRAILROAD
CO28989856Medicaid
COP00473003Medicare PIN
COC483348Medicare PIN