Basic Information
| Provider Information | |||||||||
| NPI: | 1275202095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENN | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5508 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234710508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573403489 | ||||||||
| FaxNumber: | 7573404278 | ||||||||
| Practice Location | |||||||||
| Address1: | 11835 FISHING POINT DR STE 104 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236062584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575995588 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2021 | ||||||||
| LastUpdateDate: | 09/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024182616 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.