Provider Demographics
NPI:1952176653
Name:PENNYBAKER, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:PENNYBAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 1/2 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812
Mailing Address - Country:US
Mailing Address - Phone:740-552-1400
Mailing Address - Fax:
Practice Address - Street 1:590 CALDERSBURGH ST
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-1000
Practice Address - Country:US
Practice Address - Phone:740-502-2907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide