Basic Information
| Provider Information | |||||||||
| NPI: | 1649509134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEN | ||||||||
| FirstName: | CHANTHOL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2151 E PALMDALE BLVD | ||||||||
| Address2: | SUITE | ||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935504037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619422391 | ||||||||
| FaxNumber: | 6615750015 | ||||||||
| Practice Location | |||||||||
| Address1: | 822 EAST AVENUE K | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935355938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6615799760 | ||||||||
| FaxNumber: | 6615799765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2009 | ||||||||
| LastUpdateDate: | 08/28/2013 | ||||||||
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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 | 9232475 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 20656 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.