Provider Demographics
NPI:1275384836
Name:PAVLISIN, PENNIE GUNN (RN)
Entity Type:Individual
Prefix:
First Name:PENNIE
Middle Name:GUNN
Last Name:PAVLISIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1364 LANTERN LIGHTS CIR # 1364
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IL
Mailing Address - Zip Code:62254-1841
Mailing Address - Country:US
Mailing Address - Phone:301-801-6140
Mailing Address - Fax:
Practice Address - Street 1:1364 LANTERN LIGHTS CIR # 1364
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IL
Practice Address - Zip Code:62254-1841
Practice Address - Country:US
Practice Address - Phone:301-801-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041416715163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse