Provider Demographics
NPI:1831266238
Name:PENITENTI, GILLIAN A (ABOC)
Entity type:Individual
Prefix:
First Name:GILLIAN
Middle Name:A
Last Name:PENITENTI
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 30TH ST STE G-2
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3301
Mailing Address - Country:US
Mailing Address - Phone:510-836-2353
Mailing Address - Fax:510-836-3517
Practice Address - Street 1:411 30TH ST STE G-2
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3301
Practice Address - Country:US
Practice Address - Phone:510-836-2353
Practice Address - Fax:510-836-3517
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA061013156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician