Provider Demographics
NPI:1447856158
Name:EAGLE, PENNY
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:EAGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 3RD DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST. ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177
Mailing Address - Country:US
Mailing Address - Phone:304-421-5256
Mailing Address - Fax:
Practice Address - Street 1:18 3RD DRIVE
Practice Address - Street 2:
Practice Address - City:ST. ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177
Practice Address - Country:US
Practice Address - Phone:304-421-5256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant