Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2081P2900X | Pain Medicine | 0101231849 | VA |
Y | 2081S0010X | Sports Medicine | 0101231849 | VA |
Y | 213ES0000X | Sports Medicine | 0101231849 | VA |
NPI | 1497791669 |
---|---|
Provider Name | Ms. Tracey O Pennington |
First Address | Virginia Beach, VA 23464-4122 |
Second Address | Virginia Beach, VA 23464-4122 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2006 |
Last Update Date | 03/02/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H70222 | (02) | WV |