Provider Demographics
NPI:1053872895
Name:PENNOCK, EMMA ELEANOR TAYLOR (PA-C)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:ELEANOR TAYLOR
Last Name:PENNOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 FENWOOD RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-732-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01343363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant