Provider Demographics
NPI:1003907478
Name:PENROSE, KAREN C (NP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:C
Last Name:PENROSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 MOHAWK ST STE E
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1768
Mailing Address - Country:US
Mailing Address - Phone:912-925-0067
Mailing Address - Fax:912-927-0267
Practice Address - Street 1:900 MOHAWK ST STE E
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1768
Practice Address - Country:US
Practice Address - Phone:912-925-0067
Practice Address - Fax:912-927-0267
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN101568207ND0900X, 207NP0225X, 207NS0135X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA341107OtherWELLCARE NUMBER
GA10053251OtherAMERIGROUP NUMBER
GA000741606CMedicaid
GA000741606EMedicaid
GA000741606FMedicaid
GA3311616OtherWELLCARE NUMBER
GA000741606DMedicaid