Provider Demographics
NPI:1871371716
Name:PENNINGTON, ALEXIS AMBROSE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:AMBROSE
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:AMBROSE
Other - Last Name:RUDD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:809 50TH ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-2019
Mailing Address - Country:US
Mailing Address - Phone:757-895-5465
Mailing Address - Fax:
Practice Address - Street 1:5604 VIRGINIA BEACH BLVD STE 101
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5631
Practice Address - Country:US
Practice Address - Phone:757-455-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006328235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist