Provider Demographics
NPI:1174720676
Name:FITZPATRICK, PENNY R (OTR)
Entity type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:R
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 VILLAGE DR
Mailing Address - Street 2:APT A
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3644
Mailing Address - Country:US
Mailing Address - Phone:574-252-0488
Mailing Address - Fax:
Practice Address - Street 1:1950 RIDGEDALE RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2243
Practice Address - Country:US
Practice Address - Phone:574-291-6722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003182A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist