MEDICARE: LESLIE JONES PENNINGTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0400X	Case Management Registered Nurse	RN069507	GA

General Provider Information

NPI Number	:	1629697826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE JONES PENNINGTON

Provider Business Mailing Address
First Line	:	5505 PEACHTREE DUNWOODY RD STE 200
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-1749
Country	:	US
Telephone Number	:	404-561-1924
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 PEACHTREE DUNWOODY RD STE 200
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-1749
Country	:	US
Telephone Number	:	404-355-0743
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2020
Last Update Date	:	04/09/2020

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