Healthcare Provider Details

I. General information

NPI: 1891117545
Provider Name (Legal Business Name): PENNY FOSSMAN APRN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 S MAIN ST
RANDOLPH VT
05060
US

IV. Provider business mailing address

PO BOX 1716
HAINES AK
99827-1716
US

V. Phone/Fax

Practice location:
  • Phone: 802-728-7000
  • Fax:
Mailing address:
  • Phone: 907-314-0525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number101.0134278
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberNUR R 33273
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number026.0137896
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: