Provider Demographics
NPI:1700076064
Name:PENNIMAN, WAYNE ALLEN (DPT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:ALLEN
Last Name:PENNIMAN
Suffix:
Gender:M
Credentials:DPT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MA
Mailing Address - Zip Code:01510-1469
Mailing Address - Country:US
Mailing Address - Phone:508-826-5968
Mailing Address - Fax:
Practice Address - Street 1:45 HIGH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MA
Practice Address - Zip Code:01510-2906
Practice Address - Country:US
Practice Address - Phone:508-826-5968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110122251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic