Healthcare Provider Details

I. General information

NPI: 1194717157
Provider Name (Legal Business Name): SUSAN KAY PENNYPACKER FNP C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 OLD GRAY STATION RD SUITE 200
GRAY TN
37615
US

IV. Provider business mailing address

140 OLD GRAY STATION RD SUITE 200
GRAY TN
37615
US

V. Phone/Fax

Practice location:
  • Phone: 423-477-2042
  • Fax: 423-477-7571
Mailing address:
  • Phone: 423-477-2042
  • Fax: 423-477-7571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6966
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: