Basic Information
Provider Information | |||||||||
NPI: | 1336636265 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NP GERIATRIC ADULT CARE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1048 TERRACE DR | ||||||||
Address2: |   | ||||||||
City: | MARION | ||||||||
State: | VA | ||||||||
PostalCode: | 243544138 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2767831827 | ||||||||
FaxNumber: | 2767832879 | ||||||||
Practice Location | |||||||||
Address1: | 500 CLINIC DR | ||||||||
Address2: |   | ||||||||
City: | CEDAR BLUFF | ||||||||
State: | VA | ||||||||
PostalCode: | 246099406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2765969750 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2018 | ||||||||
LastUpdateDate: | 04/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PENNINGTON | ||||||||
AuthorizedOfficialFirstName: | TERESA | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2767598825 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | AGPCNP-BC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 0024175955 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.