Provider Demographics
NPI:1265551899
Name:PENNELLA, MARYGRACE (DC)
Entity type:Individual
Prefix:DR
First Name:MARYGRACE
Middle Name:
Last Name:PENNELLA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9780 LANTERN RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-4092
Mailing Address - Country:US
Mailing Address - Phone:317-863-0365
Mailing Address - Fax:
Practice Address - Street 1:9780 LANTERN RD
Practice Address - Street 2:SUITE 230
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-4092
Practice Address - Country:US
Practice Address - Phone:317-863-0365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001966A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200316610AMedicaid
INU89878Medicare UPIN
IN234730Medicare ID - Type Unspecified