Provider Demographics
NPI:1245543164
Name:PENELTON, KARYLE (PT)
Entity type:Individual
Prefix:
First Name:KARYLE
Middle Name:
Last Name:PENELTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PROFESSIONAL DR STE 10
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5068
Mailing Address - Country:US
Mailing Address - Phone:618-462-4621
Mailing Address - Fax:618-462-6323
Practice Address - Street 1:1 PROFESSIONAL DR STE 10
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5068
Practice Address - Country:US
Practice Address - Phone:618-462-4621
Practice Address - Fax:618-462-6323
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT00157Medicare PIN