Provider Demographics
NPI:1780116178
Name:PENTON, ANDREA (PHD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:PENTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 INDIGO CREEK TRL
Mailing Address - Street 2:#1072 EAST WING
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-2564
Mailing Address - Country:US
Mailing Address - Phone:919-309-7195
Mailing Address - Fax:
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:#1072 EAST WING
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4220
Practice Address - Country:US
Practice Address - Phone:984-974-1790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2013139247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician