Provider Demographics
NPI:1063535730
Name:ROBERSON, PENNY LAINE (RN)
Entity type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:LAINE
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:575 GROGAN STREET
Mailing Address - City:LAVONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30553-0279
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 N BOULEVARD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-1906
Practice Address - Country:US
Practice Address - Phone:706-282-4507
Practice Address - Fax:706-282-4511
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN139978163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse