Provider Demographics
NPI:1710420807
Name:GREAVES, PENNY D (PMHNP-BC, FNP)
Entity type:Individual
Prefix:MS
First Name:PENNY
Middle Name:D
Last Name:GREAVES
Suffix:
Gender:F
Credentials:PMHNP-BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 CAMINO DEL RIO S STE 210
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3547
Mailing Address - Country:US
Mailing Address - Phone:196-255-1652
Mailing Address - Fax:619-324-7761
Practice Address - Street 1:438 CAMINO DEL RIO S STE 210
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3547
Practice Address - Country:US
Practice Address - Phone:619-255-1652
Practice Address - Fax:619-324-7761
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-22
Last Update Date:2025-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95110928163W00000X
CANP95005526363LF0000X
CA95005526363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily