Provider Demographics
NPI:1194717157
Name:PENNYPACKER, SUSAN KAY (FNP C)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KAY
Last Name:PENNYPACKER
Suffix:
Gender:F
Credentials:FNP C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:140 OLD GRAY STATION RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615
Mailing Address - Country:US
Mailing Address - Phone:423-477-2042
Mailing Address - Fax:423-477-7571
Practice Address - Street 1:140 OLD GRAY STATION RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615
Practice Address - Country:US
Practice Address - Phone:423-477-2042
Practice Address - Fax:423-477-7571
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN6966363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440517Medicaid
TN5440517Medicaid