Basic Information
| Provider Information | |||||||||
| NPI: | 1730514191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRAKE | ||||||||
| FirstName: | PENNE | ||||||||
| MiddleName: | PERRY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DNP, NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PERRY | ||||||||
| OtherFirstName: | PENNE | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DNP, NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 37174 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212973174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5714235699 | ||||||||
| FaxNumber: | 5714235698 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 GALLOWS RD | ||||||||
| Address2: | |||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220423307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037766558 | ||||||||
| FaxNumber: | 7037763503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2013 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 17921 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363L00000X | 17921 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 0024174843 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.