Individual
CRAIG S PENNELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
1824 DECLARATION DR, INDEPENDENCE, KY 41051-8432
(859) 363-3347
Mailing address
1824 DECLARATION DR, INDEPENDENCE, KY 41051-8196
(859) 363-3347
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1168DT
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0966101
MEDICARE ID
KY
05
—
77011682
—
KY
Enumeration date
12/12/2006
Last updated
10/14/2013
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