Healthcare Provider Details

I. General information

NPI: 1093793622
Provider Name (Legal Business Name): MICHELE LEE PENNINGTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 GRIFFIN AVE
EASTMAN GA
31023-6718
US

IV. Provider business mailing address

817 GRIFFIN AVE
EASTMAN GA
31023-6718
US

V. Phone/Fax

Practice location:
  • Phone: 478-374-0020
  • Fax: 478-374-2937
Mailing address:
  • Phone: 478-374-0020
  • Fax: 478-374-2937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301070192
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number063003
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: