Provider Demographics
NPI:1649433202
Name:PENNINGTON, AMANDA (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BUTCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:812 GORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3181
Mailing Address - Country:US
Mailing Address - Phone:304-637-3894
Mailing Address - Fax:304-637-0435
Practice Address - Street 1:812 GORMAN AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3181
Practice Address - Country:US
Practice Address - Phone:304-637-3894
Practice Address - Fax:304-637-0435
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24442208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810020336Medicaid
WV3810020336Medicaid