Healthcare Provider Details

I. General information

NPI: 1447399142
Provider Name (Legal Business Name): PENNIE DLAYNE PETERS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6034
US

IV. Provider business mailing address

105 TANASIE ST
ELIZABETHTON TN
37643-6258
US

V. Phone/Fax

Practice location:
  • Phone: 423-975-2200
  • Fax: 423-975-2210
Mailing address:
  • Phone: 423-474-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN0000100326
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: