Basic Information
| Provider Information | |||||||||
| NPI: | 1306436993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | PENELOPE | ||||||||
| MiddleName: | ALEJANDRA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5665 NEW NORTHSIDE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303284617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708745400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 303 PARKWAY DR NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303121212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042654136 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2021 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN2236270 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.