Provider Demographics
NPI:1740962661
Name:PENNINGTON, STEFANIE SUE (LPN)
Entity type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:SUE
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:STEFANIE
Other - Middle Name:SUE
Other - Last Name:PRYOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:101 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-5843
Mailing Address - Country:US
Mailing Address - Phone:573-686-5090
Mailing Address - Fax:
Practice Address - Street 1:101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5843
Practice Address - Country:US
Practice Address - Phone:573-686-5090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007030910164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse