Healthcare Provider Details

I. General information

NPI: 1952992547
Provider Name (Legal Business Name): PENNY MARIE DILORENZO CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/04/2022
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

694 SADDLE CIR
WAYCROSS GA
31503-7930
US

IV. Provider business mailing address

694 SADDLE CIR
WAYCROSS GA
31503-7930
US

V. Phone/Fax

Practice location:
  • Phone: 912-337-7789
  • Fax:
Mailing address:
  • Phone: 912-337-7789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: