Basic Information
| Provider Information | |||||||||
| NPI: | 1982050860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | RENA | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1167 SPRATLIN PARK DR | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376156205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234673600 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 LENA DR | ||||||||
| Address2: | |||||||||
| City: | ROGERSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378572951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232729239 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2016 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 67102 | TN | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.