Basic Information
| Provider Information | |||||||||
| NPI: | 1346232022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENNINGTON | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROOKS | ||||||||
| OtherFirstName: | HOLLY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 26837 MAPLE VALLEY BLACK DIAMOND RD SE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MAPLE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980389917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254134427 | ||||||||
| FaxNumber: | 4254134402 | ||||||||
| Practice Location | |||||||||
| Address1: | 8910 184TH AVE E | ||||||||
| Address2: | |||||||||
| City: | BONNEY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983918531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538637510 | ||||||||
| FaxNumber: | 2538635970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 11/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00008860 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8333379 | 05 | WA | MEDICAID |