Healthcare Provider Details

I. General information

NPI: 1023604881
Provider Name (Legal Business Name): JENNIFER PEREWIZNYK BEW RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 LAKE PAMONA RD
MIDWAY GA
31320-6557
US

IV. Provider business mailing address

485 LAKE PAMONA RD
MIDWAY GA
31320-6557
US

V. Phone/Fax

Practice location:
  • Phone: 912-610-0847
  • Fax:
Mailing address:
  • Phone: 912-610-0847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN258207
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: