Provider Demographics
NPI:1184022964
Name:PENICK, JOSEPH C III (CRNA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:C
Last Name:PENICK
Suffix:III
Gender:M
Credentials:CRNA
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2855 OLD HIGHWAY 5
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6248
Mailing Address - Country:US
Mailing Address - Phone:706-632-3711
Mailing Address - Fax:706-946-4430
Practice Address - Street 1:1968 PEACHTREE RD., NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:404-351-7121
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2015-10-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARN211608367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse