Provider Demographics
NPI:1255878641
Name:PENFOLD, ANNISA SUZETTE (PTA)
Entity type:Individual
Prefix:
First Name:ANNISA
Middle Name:SUZETTE
Last Name:PENFOLD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9468 E COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4150
Mailing Address - Country:US
Mailing Address - Phone:407-281-3803
Mailing Address - Fax:407-249-8916
Practice Address - Street 1:5006 COPPER AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1301
Practice Address - Country:US
Practice Address - Phone:505-268-7988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26785225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant