Provider Demographics
NPI:1295723526
Name:PENNINGTON, LORI MANDY (OD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:MANDY
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6315 NORTH CENTER DR
Mailing Address - Street 2:BLDG 20 SUITE 230
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3931
Mailing Address - Country:US
Mailing Address - Phone:757-461-7974
Mailing Address - Fax:757-461-4829
Practice Address - Street 1:6315 NORTH CENTER DR
Practice Address - Street 2:BLDG 20 SUITE 230
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3931
Practice Address - Country:US
Practice Address - Phone:757-461-7974
Practice Address - Fax:757-461-4829
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001488152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010198453Medicaid
VA008184M26Medicare PIN
V06013Medicare UPIN