Provider Demographics
NPI:1457994220
Name:FOVALL, PENELOPE JAYNE (MAC, LAC)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:JAYNE
Last Name:FOVALL
Suffix:
Gender:F
Credentials:MAC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8606 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-3754
Mailing Address - Country:US
Mailing Address - Phone:240-423-9592
Mailing Address - Fax:
Practice Address - Street 1:8720 GEORGIA AVE STE 300
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3614
Practice Address - Country:US
Practice Address - Phone:301-565-4924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02671171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist