Provider Demographics
NPI:1255578886
Name:PENN, LOLITA D (OWNER)
Entity type:Individual
Prefix:
First Name:LOLITA
Middle Name:D
Last Name:PENN
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:701 RUSSELL AVE STE D205
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2641
Mailing Address - Country:US
Mailing Address - Phone:301-948-1868
Mailing Address - Fax:301-948-7263
Practice Address - Street 1:701 RUSSELL AVE STE D205
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2641
Practice Address - Country:US
Practice Address - Phone:301-948-1868
Practice Address - Fax:301-948-7263
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13544230156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician