Provider Demographics
NPI:1215234778
Name:MEDICINEBEAR, PENNY ANN
Entity type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:ANN
Last Name:MEDICINEBEAR
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:PO BOX 433
Mailing Address - Street 2:
Mailing Address - City:SMITHS GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42171-0433
Mailing Address - Country:US
Mailing Address - Phone:270-784-7079
Mailing Address - Fax:270-451-1200
Practice Address - Street 1:224 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:SMITHS GROVE
Practice Address - State:KY
Practice Address - Zip Code:41217
Practice Address - Country:US
Practice Address - Phone:270-784-7079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3585344600000X
KY3586344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3162Medicaid
KY4039872241Medicare NSC