Provider Demographics
NPI:1447251830
Name:PENNY, STEPHANIE MARIE (PA)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:PENNY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13575 NW 1ST LN STE 10
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-3735
Mailing Address - Country:US
Mailing Address - Phone:352-260-0170
Mailing Address - Fax:
Practice Address - Street 1:13575 NW 1ST LN STE 10
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:FL
Practice Address - Zip Code:32669-3735
Practice Address - Country:US
Practice Address - Phone:352-559-3978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1642363AS0400X
FLPA9101259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1219PAMedicaid
FL006370300Medicaid
FLE5471YMedicare ID - Type Unspecified
SC1219PAMedicaid
FLE5471WMedicare PIN