Basic Information
| Provider Information | |||||||||
| NPI: | 1629205315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENNEBAKER | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 PRYTANIA ST | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701153500 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3525 PRYTANIA ST | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701153500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048978970 | ||||||||
| FaxNumber: | 5048978777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2009 | ||||||||
| LastUpdateDate: | 11/03/2010 | ||||||||
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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 | 363LF0000X | AP03897 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1893528 | 05 | LA | MEDICAID |