Provider Demographics
NPI:1649509134
Name:PEN, CHANTHOL (FNP)
Entity type:Individual
Prefix:MISS
First Name:CHANTHOL
Middle Name:
Last Name:PEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2151 E PALMDALE BLVD
Mailing Address - Street 2:SUITE
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-4037
Mailing Address - Country:US
Mailing Address - Phone:661-942-2391
Mailing Address - Fax:661-575-0015
Practice Address - Street 1:822 EAST AVENUE K
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-5938
Practice Address - Country:US
Practice Address - Phone:661-579-9760
Practice Address - Fax:661-579-9765
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL9232475363LF0000X
CA20656363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily