Provider Demographics
NPI:1093937344
Name:WEAVER-RANDLE, PENNY ANN (LPN)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:ANN
Last Name:WEAVER-RANDLE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 BARCLAY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39702-4425
Mailing Address - Country:US
Mailing Address - Phone:662-327-7315
Mailing Address - Fax:662-328-9854
Practice Address - Street 1:383 BARCLAY DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39702-4425
Practice Address - Country:US
Practice Address - Phone:662-327-7315
Practice Address - Fax:662-328-9854
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP260275164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770537Medicaid