Provider Demographics
NPI:1386180610
Name:PENNINGTON, SONJA (CNP)
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:SONJA
Other - Middle Name:
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:MS
Mailing Address - Zip Code:38957-0115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2372 US-49E UNIT 240
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:MS
Practice Address - Zip Code:38957
Practice Address - Country:US
Practice Address - Phone:662-375-9310
Practice Address - Fax:662-375-9311
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901711363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00721224Medicaid
MS00176836Medicaid