Individual
PENNY S DIVITA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
830 PENNSYLVANIA AVE, STE 200, CHARLESTON, WV 25302-3302
(304) 388-2709
Mailing address
830 PENNSYLVANIA AVE, STE 200, CHARLESTON, WV 25302-3302
(304) 388-2709
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
1461
WV
208000000X
Pediatrics Physician
Primary
1451
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001718046
BLUE CROSS BLUE SHIELD
WV
05
—
0046618000
—
WV
01
—
1040493
DWC
WV
Enumeration date
01/16/2006
Last updated
06/23/2011
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