Provider Demographics
NPI:1447831730
Name:PENNINGTON, MISTY DAWN (APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 FREDA LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-5931
Mailing Address - Country:US
Mailing Address - Phone:386-527-1939
Mailing Address - Fax:
Practice Address - Street 1:311 NORTH CLYDE MORRIS BLVD SUITE 320
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114
Practice Address - Country:US
Practice Address - Phone:386-255-5331
Practice Address - Fax:386-255-3723
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11011414363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty