Provider Demographics
NPI:1174174288
Name:MONTIETH, PENNY L
Entity type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:L
Last Name:MONTIETH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 SD 28525
Mailing Address - Street 2:
Mailing Address - City:JUNCTION
Mailing Address - State:TX
Mailing Address - Zip Code:76849-6246
Mailing Address - Country:US
Mailing Address - Phone:830-640-3360
Mailing Address - Fax:
Practice Address - Street 1:398 SD 28525
Practice Address - Street 2:
Practice Address - City:JUNCTION
Practice Address - State:TX
Practice Address - Zip Code:76849-6246
Practice Address - Country:US
Practice Address - Phone:830-640-3360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty