Provider Demographics
NPI:1871364646
Name:PENIEL INTERVENTIONAL CARE
Entity type:Organization
Organization Name:PENIEL INTERVENTIONAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELSIE
Authorized Official - Middle Name:ANTWIWAA
Authorized Official - Last Name:TWENEBOAH-KODUAH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:317-797-9816
Mailing Address - Street 1:318 SPRY ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:JOPPA
Mailing Address - State:MD
Mailing Address - Zip Code:21085-5424
Mailing Address - Country:US
Mailing Address - Phone:113-177-9798
Mailing Address - Fax:
Practice Address - Street 1:318 SPRY ISLAND RD
Practice Address - Street 2:
Practice Address - City:JOPPA
Practice Address - State:MD
Practice Address - Zip Code:21085-5424
Practice Address - Country:US
Practice Address - Phone:317-797-9816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty