Provider Demographics
NPI:1356606768
Name:PENROD, MISTY MARIE (APRN)
Entity type:Individual
Prefix:MS
First Name:MISTY
Middle Name:MARIE
Last Name:PENROD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:MARIE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1053 CENTER STREET
Mailing Address - Street 2:SC HOUSE CALLS INC
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-1873
Mailing Address - Country:US
Mailing Address - Phone:800-491-0909
Mailing Address - Fax:
Practice Address - Street 1:3 PROGRESSIVE ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-5165
Practice Address - Country:US
Practice Address - Phone:843-548-0533
Practice Address - Fax:843-815-9121
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.251801-COA1363LF0000X
OH251801363LP0200X
SC23137363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP6344Medicaid
OH0091989Medicaid