Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 14647 | CA |
NPI | 1093845299 |
---|---|
Provider Name | Roberta Rae Pennington |
First Address | San Clemente, CA 92673-6213 |
Second Address | San Clemente, CA 92673-6213 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/03/2007 |
Last Update Date | 28/02/2012 |