Basic Information
| Provider Information | |||||||||
| NPI: | 1720445463 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENNINGTON | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14030 HIGHWAY 160 | ||||||||
| Address2: | |||||||||
| City: | HARVIELL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639458161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737144228 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 OAK GROVE RD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737762600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2016 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2016001340 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.