Provider Demographics
NPI:1275878779
Name:PENKA CORRIVEAU, GINA MARIE (CPM, IBCLC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:PENKA CORRIVEAU
Suffix:
Gender:F
Credentials:CPM, IBCLC
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:PENKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPM, IBCLC
Mailing Address - Street 1:1170 MOCKINGBIRD ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-7462
Mailing Address - Country:US
Mailing Address - Phone:720-319-0135
Mailing Address - Fax:720-319-0135
Practice Address - Street 1:1170 MOCKINGBIRD ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-7462
Practice Address - Country:US
Practice Address - Phone:720-319-0135
Practice Address - Fax:720-319-0135
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2017-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula
No176B00000XOther Service ProvidersMidwife