Basic Information
| Provider Information | |||||||||
| NPI: | 1275572661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENNOCK | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAIBE | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MS, PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10128 W BROAD ST BLDG III | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230606761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042179210 | ||||||||
| FaxNumber: | 8042179213 | ||||||||
| Practice Location | |||||||||
| Address1: | 10128 W BROAD ST BLDG III | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230606761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042179210 | ||||||||
| FaxNumber: | 8042179213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 2305202695 | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 2305202695 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 540885859 | 01 | VA | CORVEL | OTHER | 258462 | 01 | VA | SOUTHERN HEALTH | OTHER | 98999 | 01 | VA | OPTIMA HEALTH | OTHER | 540885859 | 01 | VA | FOCUS | OTHER | 540885859 | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | 540885859 | 01 | VA | MULTIPLAN | OTHER | 540885859 | 01 | VA | PRIVATE HEALTHCARE SYSTEM | OTHER | 540885859 | 01 | VA | COMPMANAGEMENT | OTHER | 010206626 | 05 | VA | MEDICAID | 192289 | 01 | VA | ANTHEM HANOVER PT | OTHER | 540885859 | 01 | VA | C&O EMPLOYEE'S HEALTHCARE | OTHER | 540885859 | 01 | VA | FIRST HEALTH/CCN | OTHER |