Provider Demographics
NPI:1205394822
Name:MUMFORD, PENNICA MARIE (BSN,MSN, RN)
Entity Type:Individual
Prefix:MISS
First Name:PENNICA
Middle Name:MARIE
Last Name:MUMFORD
Suffix:
Gender:F
Credentials:BSN,MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4113 FENWICK VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-5513
Mailing Address - Country:US
Mailing Address - Phone:912-844-6497
Mailing Address - Fax:
Practice Address - Street 1:1395 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3901
Practice Address - Country:US
Practice Address - Phone:912-656-4456
Practice Address - Fax:912-721-0121
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN168735163WA2000X, 163WC0400X, 163WC1600X, 163WG0600X, 163WI0500X, 163WN1003X, 163WP0807X, 163WP0809X, 163WW0000X, 163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WW0000XNursing Service ProvidersRegistered NurseWound Care