Healthcare Provider Details

I. General information

NPI: 1821497942
Provider Name (Legal Business Name): PROVIDENCE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 OLD GRAY STATION ROAD SUITE 200
GRAY TN
37615-3612
US

IV. Provider business mailing address

140 OLD GRAY STATION ROAD SUITE 200
GRAY TN
37615-3612
US

V. Phone/Fax

Practice location:
  • Phone: 423-477-2042
  • Fax: 423-477-4571
Mailing address:
  • Phone: 423-477-2042
  • Fax: 423-477-4571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6966
License Number StateTN

VIII. Authorized Official

Name: MS. SUSAN KAY PENNYPACKER
Title or Position: OWNER
Credential: FNP-C
Phone: 423-477-2042