Basic Information
| Provider Information | |||||||||
| NPI: | 1184022964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENICK | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2855 OLD HIGHWAY 5 | ||||||||
| Address2: | |||||||||
| City: | BLUE RIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305136248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066323711 | ||||||||
| FaxNumber: | 7069464430 | ||||||||
| Practice Location | |||||||||
| Address1: | 1968 PEACHTREE RD., NW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043511745 | ||||||||
| FaxNumber: | 4043517121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2014 | ||||||||
| LastUpdateDate: | 10/01/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN211608 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | RN211608 | GA | N | Nursing Service Providers | Registered Nurse |
No ID Information.