Provider Demographics
NPI:1881978260
Name:PENNY, KERRYANN MELISSA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KERRYANN
Middle Name:MELISSA
Last Name:PENNY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16318 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4919
Mailing Address - Country:US
Mailing Address - Phone:347-307-5857
Mailing Address - Fax:
Practice Address - Street 1:16318 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4919
Practice Address - Country:US
Practice Address - Phone:347-307-5857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY646650163W00000X
NY404360363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse