Provider Demographics
NPI:1811156060
Name:EDOIMIOYA, PENNY
Entity type:Individual
Prefix:MISS
First Name:PENNY
Middle Name:
Last Name:EDOIMIOYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 MERRILL AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-3108
Mailing Address - Country:US
Mailing Address - Phone:312-806-0960
Mailing Address - Fax:
Practice Address - Street 1:539 MERRILL AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-3108
Practice Address - Country:US
Practice Address - Phone:312-806-0960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILE35067255648172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver